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Chapter 6: National Health Programmes

LONG QUESTIONS

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1. National Health Mission (NHM)

Definition and Background

Objectives of NHM

• Reduce Maternal Mortality Rate (MMR) to 1/1000 live births
• Reduce Infant Mortality Rate (IMR) to 25/1000 live births
• Reduce Total Fertility Rate (TFR) to 2.1
• Prevent and reduce mortality and morbidity from communicable and non-communicable diseases
• Achieve universal access to equitable, affordable, accountable quality health services

Two Sub-Missions

• Launched: April 5, 2005
• Target: Rural population, especially 18 high-focus states (8 Empowered Action Group [EAG] states + 8 North-East states + J&K + Himachal Pradesh)
• Key strategies:
  • ASHA (Accredited Social Health Activist) - community health worker
  • Strengthening of Sub-centres, PHCs, CHCs
  • Village Health, Sanitation and Nutrition Committee (VHSNC)
  • Untied funds to health facilities
  • Rogi Kalyan Samiti (RKS) - hospital management committees
  • Janani Suraksha Yojana (JSY)
  • Mobile Medical Units (MMU)
  • HBNC (Home Based Newborn Care)
  • Indian Public Health Standards (IPHS)

• Target: Urban poor, slum dwellers
• Key strategies:
  • Mahila Arogya Samiti (MAS) - urban equivalent of VHSNC
  • Urban Health Centres (UHC) - for 50,000 population
  • Urban Community Health Centres (UCHC)
  • ASHA in urban areas
  • Mapping of urban slums

Key Components of NHM

1. Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A)
2. Communicable Disease Control - NTEP, NVBDCP, NACP
3. Non-Communicable Diseases - NPCDCS, NPCBVI
4. Infrastructure & Human Resources - IPHS norms
5. Health System Strengthening - HMIS, community participation
6. Financing - flexipooling (RMNCH+A pool, communicable disease pool, NCD pool, infrastructure pool)

Flexipooling under NHM

• RCH Flexi-pool
• Mission Flexi-pool (Additionalities)
• Immunization
• NDCP (National Disease Control Programs)
• Infrastructure Maintenance

Achievements

• Significant decline in MMR, IMR, and TFR
• Expansion of institutional deliveries through JSY/JSSK
• Increase in ASHA coverage nationwide

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2. RMNCH+A (Reproductive, Maternal, Newborn, Child and Adolescent Health)

Background

Continuum of Care Approach

• Household and community level
• Outreach/Mobile team level
• Health facility level

Key Components

• Family planning services (spacing, limiting)
• Contraceptive services: Copper T 380A, Antara (DMPA injectable), Chhaya (centchroman), condoms, OCPs
• Eligible couple registration
• Infertility services

• ANC: Minimum 4 ANC visits (WHO recommends 8), now upgraded to early registration (<12 weeks)
• Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) - 9th of every month
• SUMAN (Surakshit Matritva Aashwasan) scheme
• Janani Suraksha Yojana (JSY) - cash incentive for institutional delivery
• Janani Shishu Suraksha Karyakram (JSSK) - free services for pregnant women and sick newborns
• LaQshya - quality improvement in labor rooms and maternity OTs
• Maternal Death Review (MDR)
• Obstetric care: BEmONC and CEmONC facilities

• Home-Based Newborn Care (HBNC) - by ASHA, 7 visits in 42 days
• Facility-Based Newborn Care (FBNC)
• Newborn Stabilization Units (NBSU) - at FRUs
• Special Newborn Care Units (SNCU) - at district hospitals
• Newborn corners in all delivery points
• Kangaroo Mother Care (KMC)
• Essential Newborn Care (ENC)

• IMNCI (Integrated Management of Neonatal and Childhood Illness)
• RBSK (Rashtriya Bal Swasthya Karyakram) - health screening of children 0-18 years
• Nutritional Rehabilitation Centres (NRC) - for SAM children
• Vitamin A prophylaxis
• Universal Immunization Programme (UIP)
• HBYC (Home Based Care for Young Child) - extension of HBNC

• Weekly Iron and Folic Acid Supplementation (WIFS)
• Adolescent Friendly Health Clinics (AFHCs)
• Menstrual Hygiene Scheme (MHS) - subsidized sanitary napkins (branded as "Freedays")
• ARSH (Adolescent Reproductive and Sexual Health) services
• Peer educators

Five-by-Five Matrix

• Life stages: Pre-conception → Pregnancy → Birth → Newborn/Infant → Child/Adolescent
• Platforms: Community, outreach, facility, referral, support

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3. Maternal Mortality Programmes

Definition

National MMR

• India MMR (SRS 2018-20): 97/100,000 live births
• SDG target: <70/100,000 live births by 2030
• NHM target: <100/100,000 live births

Causes of Maternal Death (Three Delays Model)

• Delay 1: Delay in deciding to seek care (community level)
• Delay 2: Delay in reaching care (transport/distance)
• Delay 3: Delay in receiving adequate care (facility quality)

Key Programmes for Reducing MMR

• Launched 2005 under NRHM
• Cash incentive for institutional delivery
• High Performing States (HPS): Urban - Rs. 600, Rural - Rs. 700
• Low Performing States (LPS): Urban - Rs. 1000, Rural - Rs. 1400
• ASHA gets incentive for facilitating delivery

• Launched June 2011
• Free entitlements: Free delivery, free C-section, free drugs, free diagnostics, free blood, free diet, free transport (home to facility and back), free treatment of sick newborn up to 30 days
• Extends to sick newborns up to 30 days of age

• Launched 2016
• Free comprehensive and quality ANC on 9th of every month
• Services by specialists/MOs at PHC/CHC/DH
• 3 Cs: Checkup, Certification (high-risk), Care plan

• Launched October 2019
• Zero tolerance for denial of care
• Guaranteed, dignified, respectful and quality healthcare
• Free entitlements for all pregnant women and newborns

• Launched 2017
• Quality improvement in labor rooms and maternity OTs
• Certification: Bronze, Silver, Gold
• Focus: Respectful maternity care, reducing preventable maternal and newborn deaths

• Zero preventable maternal and newborn deaths
• Minimum 4 ANCs, intrapartum care, postnatal care

• Facility-based MDR and community-based MDR
• Root cause analysis
• Corrective actions

• Train ANMs and LHVs in skilled birth attendance

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4. Anaemia Programme (ANAEMIA MUKT BHARAT)

Background

Anaemia Mukt Bharat (AMB) - Launched 2018

• Children 6-59 months
• Children 5-9 years
• Adolescents 10-19 years
• Women of reproductive age (15-49 years)
• Pregnant women
• Lactating women

6x6x6 Strategy of AMB

1. Prophylactic Iron and Folic Acid (IFA) supplementation
2. Deworming
3. Behaviour change communication (BCC) and demand generation
4. Testing of anaemia using point-of-care technology (colour scale/digital haemoglobinometer)
5. Treatment of anaemia based on protocol
6. Non-nutritional causes of anaemia addressed (malaria, hemoglobinopathies, fluorosis)

1. Intensified year-round IFA programme
2. Ensuring regular supply of IFA tablets
3. Strengthening of HMIS reporting
4. Monitoring through SNCU and NRC
5. Digital platform integration
6. Convergence with ICDS, School Health

IFA Supplementation Schedules

WIFS (Weekly Iron and Folic Acid Supplementation)

• Part of RKSK
• For school-going adolescents (10-19 years)
• Weekly supervised dose of IFA on fixed days
• Also includes biannual deworming

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5. IDD Programme (Iodine Deficiency Disorders)

Background

Spectrum of IDD

• Goitre (most visible)
• Cretinism (most severe - irreversible intellectual disability)
• Subclinical hypothyroidism
• Impaired mental function
• Increased susceptibility to nuclear radiation

National Iodine Deficiency Disorders Control Programme (NIDDCP)

• Earlier called National Goitre Control Programme (NGCP), established 1962
• Renamed NIDDCP in 1992
• Now part of National Programme for Non-Communicable Disease Prevention and Control

Key Strategies

1. Universal Salt Iodization (USI): All edible salt to be iodized at 30 ppm at production level (15 ppm at consumer level)
2. IDD Surveys: To assess magnitude of problem
3. Laboratory surveillance: Urinary iodine excretion monitoring (target >100 mcg/L median)
4. Ban on non-iodized salt: Prevention of Foods Adulteration Act prohibits non-iodized salt for direct human consumption in notified areas
5. Iodized oil capsules: For areas with severe deficiency where salt iodization not possible

Assessment Indicators

• Goitre rate: Total Goitre Rate (TGR) in school children 6-12 years; target <5%
• Urinary Iodine Excretion (UIE): Median >100 mcg/L (optimal: 100-299 mcg/L)
• Neonatal TSH: <3% neonates with TSH >5 mU/L

Iodized Salt

• Plain salt + potassium iodate (KIO₃) added
• 30 ppm at production level
• 15 ppm at consumer level
• Store in cool, dry, dark place (light and heat degrade iodine)
• Use after removing lid briefly (not before)

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6. Adolescent Programme (RKSK)

Rashtriya Kishor Swasthya Karyakram (RKSK)

• Launched: January 7, 2014
• Target population: Adolescents aged 10-19 years (~253 million in India)
• Replaces ARSH (Adolescent Reproductive and Sexual Health) programme

6 Strategy Areas

1. Nutrition - WIFS, deworming, dietary counseling
2. Sexual and Reproductive Health (SRH) - contraception, menstrual hygiene
3. Non-communicable diseases - prevention of obesity, diabetes, hypertension
4. Substance misuse - tobacco, alcohol, drugs
5. Mental health - suicide prevention, stress management
6. Gender and GBV (Gender-Based Violence)

Key Delivery Mechanisms

• Trained adolescents (peers) deliver health information to fellow adolescents
• 1 PE per 20-25 adolescents

• At PHC/CHC/DH and urban health centres
• Fixed day, fixed time services
• Confidentiality and non-judgmental approach

• Sanitary napkins ("Freedays") available at Rs. 6 for pack of 6 (subsidized)
• Available through ASHA, AWW, PHC, schools
• Targeted at adolescent girls in rural areas

• Under RBSK
• Two health and wellness teams per block
• Annual health screening

• Merged Kishori Shakti Yojana (KSY) and RGSEAG
• For girls 11-18 years
• Nutrition, IFA, health check-up, life skills, vocational training

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7. NPHCE (National Programme for Health Care of the Elderly)

Background

Launch

• Launched 2010-11 under NHM
• 12th Plan: Expanded to all states

Objectives

• Provide dedicated, comprehensive, and affordable primary health care to elderly
• Develop capacities of medical and paramedical personnel for elder care
• Provide referral services
• Support for old age homes and respite care

Service Delivery Structure

Common Health Problems Addressed

• Cardiovascular diseases, hypertension, diabetes
• COPD, arthritis, osteoporosis
• Dementia, depression, Alzheimer's disease
• Falls, fractures, functional decline
• Visual and hearing impairment
• Incontinence

National Policy on Older Persons (NPOP) - 1999

• Recognizes elderly persons as productive assets
• Financial security, health care, protection, welfare

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8. NTEP (National Tuberculosis Elimination Programme)

Background

• Earlier known as RNTCP (Revised National TB Control Programme) - launched 1997, became nationwide 2006
• Renamed to NTEP in 2020, emphasizing elimination goal
• Vision: TB-free India by 2025 (SDG target 2030)
• India has the highest TB burden - approximately 26% of global TB cases

Key Targets (National Strategic Plan 2020-2025)

• Reduce TB incidence by 80% from 2015 levels
• Reduce TB deaths by 90% from 2015 levels
• Zero catastrophic costs for TB-affected families
• End TB by 2025 (5 years ahead of SDG 2030)

DOTS Strategy

• World Bank called it "one of the most cost-effective health interventions"
• 5 elements of DOTS:
  1. Government commitment
  2. Case detection by sputum smear microscopy
  3. Standardized short-course chemotherapy under direct observation
  4. Uninterrupted supply of quality drugs
  5. Recording and reporting system

Treatment Regimens under NTEP

• Intensive Phase: 2 months of HRZE (Isoniazid + Rifampicin + Pyrazinamide + Ethambutol) daily
• Continuation Phase: 4 months of HR (Isoniazid + Rifampicin) daily
• Total: 6 months (2HRZE/4HR)

• 2 months HRZES (+ Streptomycin) / 1 month HRZE / 5 months HRE
• Being replaced by individual DST-guided therapy

• MDR-TB (Rifampicin + Isoniazid resistant): Longer regimen - BPaL (Bedaquiline, Pretomanid, Linezolid) or Bedaquiline + Levofloxacin-based regimen; Shorter MDR-TB regimen available (9-11 months)
• XDR-TB: Resistant to fluoroquinolones + at least one second-line injectable; treated with BPaL (6-9 months)
• Pre-XDR TB: MDR + fluoroquinolone resistance

Key Features of NTEP

1. Universal Drug Susceptibility Testing (UDST): Every diagnosed TB patient gets DST before treatment
2. Molecular diagnostics: CB-NAAT (Cartridge-Based Nucleic Acid Amplification Test/CBNAAT - Xpert MTB/RIF) and TrueNat at sub-district level
3. Ni-kshay portal: Web-based case notification and treatment monitoring system
4. Ni-kshay Poshan Yojana: Rs. 500/month to TB patients during treatment for nutritional support
5. Pradhan Mantri TB Mukt Bharat Abhiyan: Jan 2022 - community involvement, patient adoption by corporates/individuals
6. Private sector engagement: 99DOTS, treatment supporters
7. TB-HIV collaboration: Intensified case finding in HIV patients, ART for all TB-HIV patients
8. Preventive Therapy: 6H (Isoniazid preventive therapy, IPT) for household contacts, PLHIV

Diagnosis

• Bacteriological confirmation preferred: Sputum smear microscopy, CBNAAT, LPA (Line Probe Assay), Culture
• Clinical diagnosis: Chest X-ray + clinical features when bacteriology unavailable/negative

Recording and Reporting

• Treatment Outcomes: Cured, Treatment completed (= Treatment Success), Treatment failed, Died, Lost to follow-up, Not evaluated
• Treatment Success Rate Target: >90% for new pulmonary TB

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9. NACP (National AIDS Control Programme)

Background

• HIV first detected in India: 1986 (Chennai)
• NACP Phase I: 1992-1999
• NACP Phase II: 1999-2006
• NACP Phase III: 2007-2012
• NACP Phase IV: 2012-2017
• NACP Phase V: 2021-2026 (current)

National AIDS Control Organisation (NACO)

• Apex body for HIV/AIDS control in India
• Under Ministry of Health and Family Welfare

HIV Burden in India (NACP IV estimates)

• ~2.40 million PLHIV (People Living with HIV/AIDS)
• Adult HIV prevalence: ~0.22%
• High Prevalence States: AP, Telangana, Maharashtra, Karnataka, Tamil Nadu, Manipur, Mizoram, Nagaland
• Key affected populations: FSW, MSM, IDU, Transgender, Truckers, Migrants

95-95-95 Target (by 2030)

• 95% PLHIV know their status
• 95% of those who know their status on ART
• 95% on ART virologically suppressed

Key Services under NACP

• Targeted Interventions (TIs) for high-risk groups
• Condom promotion and distribution
• Blood safety (NACO's blood transfusion programme)
• PPTCT (Prevention of Parent to Child Transmission)
• Harm reduction (needle/syringe exchange, OST)
• IEC/BCC campaigns

• ICTC (Integrated Counselling and Testing Centres) - facility-based
• FCTC (Facility-based Counselling and Testing Centres)
• Mobile testing units
• Self-testing kits (available)

• ART Centres (at district hospitals/medical colleges)
• Link ART Centres (LAC) at CHC/PHC level
• Free ART for all PLHIV regardless of CD4 count (Option B+ / "Treat All")
• First-line: TLE regimen (Tenofovir + Lamivudine + Efavirenz) - single daily dose
• Second-line: Lopinavir/ritonavir based
• Third-line: Darunavir/ritonavir based

• Earlier called PMTCT
• All pregnant women tested for HIV at ANC
• HIV+ pregnant women given ART immediately (regardless of CD4)
• Mother: ART continued for life
• Baby: Nevirapine (NVP) 6 weeks after birth
• Avoid breastfeeding (or exclusive breastfeeding for 6 months if formula unavailable)
• Prophylactic Cotrimoxazole for HIV-exposed infants
• Early Infant Diagnosis (EID) by PCR at 6 weeks

• Integrated Counselling and Testing Centre
• Voluntary Counselling and Testing (VCT)
• Pre-test and post-test counselling
• HIV testing (ELISA/Rapid tests using strategy III - 3 different kits)
• Referral for ART, PPTCT, OI treatment

• For occupational exposure (needlestick) and non-occupational exposure (sexual assault)
• Start within 72 hours (ideally within 2 hours)
• Duration: 28 days
• Regimen: TDF + 3TC + LPV/r or RAL
• Follow-up testing at 6 weeks, 3 months, 6 months

DMHP Connection

• DMHP addresses mental health issues in PLHIV

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10. NVBDCP (National Vector Borne Disease Control Programme)

Background

• Launched 2003-04 by merging 5 separate programmes:
  • National Anti-Malaria Programme (NAMP)
  • National Filaria Control Programme (NFCP)
  • Kala-azar Technical Supervisory Unit
  • Dengue/DHF Control Programme
  • Japanese Encephalitis Control Programme
• Also includes: Chikungunya

Diseases Covered

1. Malaria
2. Dengue and Chikungunya
3. Lymphatic Filariasis
4. Kala-azar (Visceral Leishmaniasis)
5. Japanese Encephalitis (JE)
6. Chikungunya

Malaria Control

• Phase 1 (2016-2020): Reduce malaria mortality to near zero
• Phase 2 (2020-2022): Eliminate from 15 states
• Phase 3 (2022-2024): Interrupt transmission in remaining states
• Phase 4 (2024-2027): Nationwide elimination

• Indoor Residual Spraying (IRS)
• Insecticide-Treated Bed Nets (ITN)/Long-Lasting Insecticidal Nets (LLIN)
• Early diagnosis: RDT (Rapid Diagnostic Tests) for P. falciparum
• Prompt treatment: ACT (Artemisinin Combination Therapy) for P. falciparum
• Mass Drug Administration (MDA) in high-endemic areas
• Annual Blood Examination Rate (ABER) target: >10%

• P. falciparum: Artesunate + Sulfadoxine-Pyrimethamine (AS+SP) or Artesunate + Mefloquine
• P. vivax: Chloroquine (14 days) + Primaquine (14 days for radical cure)
• Severe malaria: IV Artesunate

Dengue Control

• No specific drug or vaccine (currently)
• Vector: Aedes aegypti (day biter)
• Source reduction: Eliminate stagnant water collections
• Larviciding with Temephos
• Personal protection: repellents, full-sleeve clothing
• Dengue NS1 antigen test (first 5 days), IgM ELISA (after 5 days)
• Notification within 24 hours

Filariasis Control

• MDA (Mass Drug Administration): Single annual dose of Diethylcarbamazine (DEC) 6mg/kg + Albendazole 400mg to entire endemic population (except contraindicated groups)
• Triple drug therapy: DEC + Albendazole + Ivermectin (IDA) being rolled out
• Morbidity management: lymphedema management

Kala-azar (Visceral Leishmaniasis) Elimination

• Target: <1 case per 10,000 population at sub-district level by 2023
• Treatment: Liposomal Amphotericin B (single dose IV) as first-line in India
• Vector control: IRS with DDT/synthetic pyrethroids, long-lasting insecticidal nets

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11. Nutrition Programmes

Major Nutrition Programmes in India

• Launched: October 2, 1975 (World's largest nutrition programme)
• Target: Children 0-6 years, pregnant and lactating women, adolescent girls
• Implementing body: Ministry of Women and Child Development (not Health)
• Delivery point: Anganwadi Centre (AWC) - 1 per 1000 population (tribal 700)
• 6 services (package):
  1. Supplementary nutrition
  2. Immunization
  3. Health check-up
  4. Referral services
  5. Pre-school non-formal education
  6. Nutrition and health education (mothers/women)
• Anganwadi Worker (AWW) - government employee, supervisor is CDPO (Child Development Project Officer)

• Launched 1995 (national); renamed PM POSHAN in 2021
• Target: School children classes 1-8 (primary and upper primary)
• Free cooked meal every school day
• Nutritional norms: 450 kcal + 12g protein (primary); 700 kcal + 20g protein (upper primary)
• Benefits: Reduced malnutrition, improved school enrolment/attendance, reduced dropout

• Maternity benefit scheme
• Rs. 5000 cash incentive in 3 installments for first living child
• Conditions: Early ANC registration, 2 ANC visits, institutional delivery + child vaccination
• Merges with JSY for institutional delivery incentive

• Mission POSHAN 2.0 launched 2021
• Targets: Stunting (from 38% to 25% by 2022)
• Wasting: 21% to 19%; Low Birth Weight: 21% to 17%; Anaemia among children: 59% to 40%; Anaemia in adolescent girls/women: 53% to 35%
• Technology: POSHAN Tracker app, ICT-based monitoring
• Convergence of ICDS, PMMVY, NHM nutrition interventions, SBCC

• For children 9 months to 5 years
• 9 months: 1 lakh IU (first dose with measles vaccine)
• 12-59 months: 2 lakh IU every 6 months
• Delivered through Vitamin A supplementation rounds (biannual)

• For adolescents 10-19 years (under RKSK)

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12. NPCBVI (National Programme for Control of Blindness and Visual Impairment)

Background

• Launched 1976
• Renamed NPCBVI (adding Visual Impairment) in 2017
• India has ~5% of world's blind population

Targets

• Reduce prevalence of blindness from 1% to <0.3%
• Vision 2020 initiative goal

Causes of Blindness in India

1. Cataract - most common (66.2%)
2. Refractive errors
3. Corneal blindness
4. Glaucoma
5. Diabetic retinopathy
6. Others

Key Interventions

• Cataract surgery: Free IOL implantation (phacoemulsification)
• National Blindness Control Survey - periodic
• School Eye Screening Programme - correction of refractive errors
• District Mobile Ophthalmic Units (DMOU)
• Vision centres at PHC level
• Eye donation promotion - National Eye Donation Fortnight (25 Aug - 8 Sept)
• Low Vision Rehabilitation Centres
• Training of ophthalmic assistants

Performance Indicator

• Cataract Surgical Rate (CSR): Number of cataract surgeries per million population per year; target: ≥4000/million

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13. NPCDCS (National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke)

Background

• Launched 2010 (pilot), nationwide rollout under NHM
• NCDs account for 60% of deaths in India

Objectives

• Prevent and control common NCDs
• Screen and detect early
• Provide treatment at primary and secondary level
• Build human resource capacity

Diseases Covered

• Cancer: Cervical, breast, oral
• Diabetes: Type 2
• Cardiovascular Diseases: Hypertension, IHD
• Stroke

Population-Based Screening (CBS)

• Cervical cancer: VIA (Visual Inspection with Acetic Acid) at PHC level
• Breast cancer: CBE (Clinical Breast Examination)
• Oral cancer: Visual inspection
• Hypertension: BP measurement
• Diabetes: Blood glucose testing (FBS/RBS)

Delivery Mechanism

• NCD clinic at CHC/District Hospital
• NCD Cell at state and district level
• Capacity building of health workers for CBS
• Free drugs at public facilities

Common Risk Factor Approach

• Address shared risk factors: tobacco, unhealthy diet, physical inactivity, harmful alcohol use, obesity

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14. Ayushman Bharat

Two Components

• Launched: April 14, 2018 (Bijapur, Chhattisgarh by PM Modi)
• Target: Convert 1,50,000 Sub-Centres and PHCs into HWCs by December 2022
• Provide Comprehensive Primary Health Care (CPHC)
• 12 service packages at HWC:
  1. Pregnancy and maternal health
  2. Neonatal/infant/child health
  3. Family planning, contraception
  4. Adolescent health
  5. NCDs - Hypertension, Diabetes, 3 common cancers
  6. Communicable diseases - DOTS, NVBDCP, leprosy
  7. Mental health
  8. Oral health
  9. Eye care and ENT
  10. Elderly care
  11. Palliative care
  12. Emergency/trauma care
• Staffed by: Mid-Level Health Provider (MLHP)/Community Health Officer (CHO) - BSc. Community Health/Ayurveda practitioners with 6-month bridge course
• Wellness activities, yoga sessions, community engagement

• Launched: September 23, 2018
• World's largest government-funded health insurance scheme
• Beneficiaries: ~10.74 crore poor and vulnerable families (bottom 40% of population) based on SECC 2011 data
• Coverage: Rs. 5 lakh per family per year for secondary and tertiary hospitalization
• Cashless and paperless: Beneficiary uses Ayushman Card at empanelled hospital
• Covers ~1949 treatment packages (recently expanded)
• No cap on family size or age
• Includes: Pre-hospitalization (3 days), hospitalization, post-hospitalization (15 days), follow-up
• Covers 3 days prior to admission and 15 days after discharge
• Beneficiary identification: PM-JAY beneficiary list (SECC + RSBY beneficiaries)
• Technology: Ayushman Bharat - Pradhan Mantri Jan Arogya Yojana IT platform
• National Health Authority (NHA) - apex body implementing PMJAY

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15. Newborn Care

Key Programmes

• ASHA visits newborn at home
• Schedule: 3rd day, 7th day, 14th day, 21st day, 28th day, 42nd day (6 visits; with maternal visit on day 1)
• Currently being extended to 2 months (HBYC - Home Based Care for Young Child)
• Essential newborn care: warmth, breastfeeding, cord care, danger sign recognition
• Referral for sick newborns

• At every delivery point
• Equipment: Radiant warmer, Ambu bag, suction, mucus extractor
• Essential Newborn Care

• At First Referral Units (FRU/CHC)
• For newborns 1500-1800g, mild-moderate illness
• Managed by SN (Staff Nurse)

• At District Hospitals
• For sick/LBW newborns <1500g or severely ill
• Managed by Pediatrician
• SNCU data fed to SNCU online (linked to NHM)

• Skin-to-skin contact between mother and LBW/preterm baby
• Initiated in SNCU, continued at home
• Benefits: Maintains warmth, promotes breastfeeding, reduces infection, reduces mortality

• Immediate drying and warmth
• Delayed cord clamping (1-3 minutes)
• Skin-to-skin contact
• Early initiation of breastfeeding within 1 hour
• Eye care (1% tetracycline ointment)
• Vitamin K (0.5 mg IM for <1500g; 1 mg IM for >1500g) - prevents hemorrhagic disease

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16. NLEP (National Leprosy Eradication Programme)

Background

• India launched national leprosy programme in 1955
• NLEP with MDT launched 1983
• Achieved eradication at national level (<1/10,000) in 2005
• Now: Elimination at sub-district level targeted

Leprosy Treatment (MDT)

• Duration: 6 months
• Drugs: Rifampicin 600mg monthly (supervised) + Dapsone 100mg daily (self-administered)

• Duration: 12 months
• Drugs: Rifampicin 600mg monthly (supervised) + Clofazimine 300mg monthly (supervised) + Clofazimine 50mg daily (self) + Dapsone 100mg daily (self)

Key Indicators

• Prevalence Rate (PR): Target <1/10,000 population
• New Case Detection Rate (NCDR)
• Grade 2 Disability (G2D) among new cases: indicator of delay in detection
• Child proportion among new cases: indicator of active transmission

Sparsh Leprosy Awareness Campaign

• Annual campaign for leprosy case detection
• January 30 (Martyrs' Day/Gandhi's death anniversary) to February 13

Anti-Leprosy Day

• January 30

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17. NMHP (National Mental Health Programme)

Background

• Launched 1982
• District Mental Health Programme (DMHP) started 1996 (Bellary, Karnataka pilot)
• Expanded under NHM

Objectives

• Prevent and treat mental disorders
• Rehabilitate mentally ill persons
• Integrate mental health with general health care

DMHP (District Mental Health Programme)

• Operational at district level
• Core services: Outpatient, inpatient (12-bed at DH), community outreach camps, school mental health, workplace counseling, suicide prevention
• Staff: Psychiatrist, Clinical Psychologist, Psychiatric Social Worker (PSW), Psychiatric Nurse
• Mobile teams for community outreach
• 24x7 helpline (NIMHANS Vandrevala helpline: 1860-2662-345)

MHCA 2017 (Mental Healthcare Act 2017)

• Replaced MHA 1987
• Right to mental healthcare
• Advance Directive for treatment
• Decriminalization of suicide attempt
• Right to community living
• Prohibition of seclusion and restraint

iDEAL (Integration of mental health into ASHA training)

WHO's mhGAP (Mental Health Gap Action Programme) - used in India

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18. RBSK (Rashtriya Bal Swasthya Karyakram)

Launch

• February 6, 2013 under RMNCH+A/NHM

Objective

• Early identification and early intervention for children from birth to 18 years
• 4 Ds of RBSK:
  1. Defects at birth (congenital anomalies)
  2. Deficiencies (nutritional deficiencies)
  3. Diseases (childhood diseases)
  4. Developmental delays including disability

Target Population

• 0-6 years: Children at Anganwadi Centres (AWC), villages
• 6-18 years: Children in government and government-aided schools

Delivery Mechanism

• Mobile Health Teams (MHT): 2 per block (1 for community 0-6 years, 1 for schools 6-18 years)
• Each team: Medical Officer (AYUSH/MBBS), Male Health Worker (ANM/staff nurse/pharmacist), Female Health Worker
• Screening using District Early Intervention Centre (DEIC) protocols
• Referral to DEIC (District Early Intervention Centre) for confirmatory testing and management
• Free corrective surgery/management at government facilities

Conditions Screened (30 conditions)

DEIC (District Early Intervention Centre)

• Confirmatory testing and management
• Free services
• Located at district hospital
• Team: Paediatrician, Medical Officer (AYUSH), Dental Surgeon, Physiotherapist, Speech therapist, Audiologist, Psychologist, Social Worker, Optometrist

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19. IMNCI (Integrated Management of Neonatal and Childhood Illness)

Background

• WHO/UNICEF developed IMCI (Integrated Management of Childhood Illness) in 1992
• India adapted as IMNCI adding "Neonatal" component
• Covers children 0-5 years (IMCI was 2 months-5 years)

Objectives

• Reduce under-5 mortality
• Reduce morbidity
• Improve nutrition
• Improve growth and development

Three Components

1. Improving case management skills of health workers
2. Improving health systems (drug supply, referral system)
3. Improving family and community practices

IMNCI Age Groups

• 0-2 months (Young Infant): Possible serious bacterial infection, local bacterial infection, jaundice, diarrhea, feeding problems, low weight, immunization
• 2 months-5 years: General danger signs, cough/breathing, diarrhea, fever, ear problems, malnutrition, anemia, immunization, vitamin A

Algorithm (Assess-Classify-Treat-Counsel-Follow-up)

1. Assess: Check for danger signs, symptoms
2. Classify: Using color-coded system (Red = urgent referral; Yellow = treat and advise; Green = home care)
3. Treat/Refer: Based on classification
4. Counsel: Mother on feeding, fluids, when to return
5. Follow-up: Within 2-5 days

Key Features

• Syndromic approach (not disease-specific)
• Color-coded triage
• Focus on nutrition and feeding counseling
• Emphasis on maternal and family education

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SHORT NOTES

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ICTC (Integrated Counselling and Testing Centre)

• Facility providing HIV testing with counseling
• Pre-test counseling: inform about HIV, test procedure, confidentiality, implications
• HIV testing: 3 rapid tests using 3 different kits (Strategy III) - all 3 positive = HIV positive; discordant = ELISA/Western blot
• Post-test counseling: risk reduction, partner testing, linkage to services
• Available at PHC, CHC, District Hospitals, Medical Colleges
• Some combined with ART centres

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PPTCT (Prevention of Parent to Child Transmission)

• Also written PMTCT
• HIV can transmit from mother to child: during pregnancy (10-20%), labor/delivery (most common - 50-60%), breastfeeding (30-40%)
• All pregnant women tested at first ANC contact
• HIV+ pregnant women: ART started immediately for life (Option B+)
• Baby: NVP (Nevirapine) for 6 weeks after birth
• EID (Early Infant Diagnosis) by PCR/DNA at 6 weeks
• Cotrimoxazole prophylaxis for exposed infants
• Virological suppression in mother reduces MTCT to <1%

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HIV PEP (Post-Exposure Prophylaxis)

• For healthcare workers after occupational exposure (needlestick, splash)
• Start within 72 hours (ideally <2 hours); do not start after 72 hours
• Duration: 28 days
• Regimen (India): TDF + 3TC/FTC + LPV/r or Raltegravir (RAL)
• First Aid: Wash wound with soap and water; flush mucous membrane with water; do NOT squeeze/suck
• Source assessment: Test source patient for HIV if possible
• Baseline HIV test of exposed person (EIA/Western Blot)
• Follow-up: HIV testing at 6 weeks, 3 months, 6 months
• If source HIV-negative: PEP not required (unless high-risk exposure/elite controllers)

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DMHP (District Mental Health Programme)

• Under NMHP
• Operational at district level under NHM
• Services: OPD psychiatry, inpatient (12 beds at DH), day care, mobile outreach, school mental health programme, suicide prevention, psychosocial rehabilitation
• Staff: Psychiatrist, Psychologist, PSW, Psychiatric Nurse
• Helpline services
• Walk-in counseling
• Coverage: All districts under NHM

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PMSMA (Pradhan Mantri Surakshit Matritva Abhiyan)

• Launched: June 9, 2016
• Free, assured, comprehensive quality ANC on 9th of every month at designated government facilities
• Services: Weight, Blood pressure, abdominal examination, Hb, urine, blood sugar, ultrasound (if available), VDRL/HIV/HBsAg
• High-risk identification and care plan
• Certification of high-risk pregnancies
• Conducted by: Specialists/Obstetricians (private sector voluntary participation)
• Dedicated PMSMA registration: Green card (normal), Red card (high-risk)

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SUMAN (Surakshit Matritva Aashwasan)

• Launched: October 10, 2019
• Guarantees:
  • Zero preventable maternal and newborn deaths
  • Zero tolerance for denial of services
  • Zero out-of-pocket expenditure
• Free entitlements include:
  • Minimum 4 ANC visits
  • Free delivery (normal or C-section)
  • Free drugs and diagnostics
  • Free transport to and from facility
  • Free blood transfusion
  • Free diet
  • Postpartum care (48 hours after normal, 72 hours after C-section)
  • Treatment of sick newborn up to 30 days
• Complaint mechanism for denial of care

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JSY (Janani Suraksha Yojana)

• Cash-transfer scheme under NRHM (2005) for institutional delivery
• Focus on Below Poverty Line (BPL) women and SC/ST women
• Two categories:
  • HPS (High Performing States): Those with >25% institutional delivery rate: Urban Rs. 600, Rural Rs. 700
  • LPS (Low Performing States): Including 10 EAG states: Urban Rs. 1000, Rural Rs. 1400
• ASHA incentive: Rs. 300 (urban), Rs. 600 (rural)
• No age or parity restriction in LPS
• In HPS: BPL + age >19 + up to 2 live births

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JSSK (Janani Shishu Suraksha Karyakram)

• Launched: June 1, 2011
• Free entitlements for all pregnant women (not just BPL):
  • Normal delivery, C-section, drugs, consumables, diagnostics, blood, diet (3 days normal, 7 days C-section), transport
• Free entitlements for sick newborns up to 30 days:
  • Treatment, drugs, diagnostics, blood, diet, transport
• Aims to eliminate out-of-pocket spending

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LaQshya (Labour Room Quality Improvement Initiative)

• Launched: December 2017
• Quality improvement in labor rooms and maternity operation theatres
• Focus on reducing preventable maternal and newborn deaths during delivery
• Certification process: Bronze (>60%), Silver (>70%), Gold (>80%) based on compliance score
• Key standards: Respectful maternity care, evidence-based practices, essential equipment, skilled staff, emergency protocols, infection prevention
• Monitoring: Structured observation, patient exit interview, record review

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RKSK (Rashtriya Kishor Swasthya Karyakram)

• Launched: January 7, 2014
• Target: 10-19 years (~253 million)
• 6 health areas: Nutrition, SRH, NCDs, substance misuse, mental health, gender/GBV
• Delivery: AFHCs, peer educators, school-based
• WIFS: Weekly IFA (Tuesdays for in-school, Thursdays for out-of-school)
• Biannual deworming (Albendazole 400mg)
• Menstrual Hygiene Scheme: "Freedays" napkins at Rs. 6 for 6
• Under RMNCH+A strategy

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Menstrual Hygiene Scheme

• Targets adolescent girls in rural areas (primarily)
• Subsidized sanitary napkins branded "Freedays" - pack of 6 at Rs. 6
• Distributed through ASHA, AWW, ANM, PHC, schools
• Aims to address school absenteeism due to menstruation
• Part of RKSK/RMNCH+A

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Mid-Day Meal (PM POSHAN)

• Renamed Pradhan Mantri Poshan Shakti Nirman (PM POSHAN) in 2021
• For classes 1-8 in government schools
• Free cooked meal every school day
• Nutritional norms:
  • Primary (classes 1-5): 450 kcal, 12g protein
  • Upper Primary (classes 6-8): 700 kcal, 20g protein
• Micronutrients: Iron, folic acid, Vitamin A included
• Benefits: Reduces malnutrition, improves school enrolment, reduces dropout (especially girls), reduces classroom hunger
• Budget 60:40 (Centre:State); 90:10 for NE states; 100% for UTs

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4 Ds of RBSK

1. Defects at birth - congenital anomalies (CHD, cleft lip/palate, NTD, clubfoot)
2. Deficiencies - nutritional (anaemia, vitamin A deficiency, iodine deficiency) and micronutrient deficiencies
3. Diseases - childhood diseases (dental caries, skin diseases, rheumatic heart disease, RTI/STI)
4. Developmental delays including disability - autism, cerebral palsy, intellectual disability, hearing/vision/locomotor impairment

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INAP (India Newborn Action Plan)

• Launched: September 17, 2014
• India's contribution to Every Newborn Action Plan (ENAP) of WHO/UNICEF
• Goal: Single-digit neonatal mortality rate (NMR) by 2030 (NMR <10/1000 live births)
• Stillbirth rate: <10/1000 total births
• Targets:
  • NMR: <16/1000 live births by 2020; <10/1000 by 2030
  • Stillbirth Rate: <10/1000 total births by 2030
• 6 Strategic Priorities ("ENRICH"):
  1. Every birth skilled attendance
  2. Newborn resuscitation
  3. Reaching the small and sick newborn (KMC, SNCU)
  4. Infection prevention and management
  5. Care of the healthy newborn
  6. Home-based care (HBNC)

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MDR/XDR TB Treatment (Under NTEP)

• Rifampicin-resistant (RR-TB) or MDR-TB
• Shorter MDR-TB Regimen (9-11 months):
  • Intensive phase (4-6 months): Bedaquiline (BDQ) + Levofloxacin + Clofazimine + Pyrazinamide + Ethambutol + Prothionamide
  • Continuation phase (5 months): Levofloxacin + Clofazimine + Pyrazinamide + Ethambutol
• BPaL Regimen (6 months): Bedaquiline + Pretomanid + Linezolid - for XDR-TB and treatment-intolerant MDR-TB (approved under NTEP)

• 2021 WHO revised definition: MDR/RR-TB + resistance to any fluoroquinolone + at least one of Bedaquiline or Linezolid
• Treatment: BPaL (Bedaquiline + Pretomanid + Linezolid) for 6 months
• Conditional: BPaLM (+ Moxifloxacin if sensitive) for 6 months

• Bedaquiline (BDQ): Diarylquinoline, inhibits mycobacterial ATP synthase
• Pretomanid: Nitroimidazole
• Linezolid: Oxazolidinone
• Clofazimine: Riminophenazine (anti-leprosy drug also used in MDR-TB)
• Delamanid: Another nitroimidazole (used in select cases)

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Leprosy Treatment (Under NLEP)

• WHO definition: 1-5 skin lesions, no nerve thickening, smear negative
• Duration: 6 months
• Drugs:
  • Monthly supervised: Rifampicin 600mg
  • Daily self-administered: Dapsone 100mg (50mg for children)

• WHO definition: >5 skin lesions, or nerve involvement, or smear positive
• Duration: 12 months
• Drugs:
  • Monthly supervised: Rifampicin 600mg + Clofazimine 300mg
  • Daily self-administered: Dapsone 100mg + Clofazimine 50mg

• Type 1 (Reversal Reaction): Treat with Prednisolone 40mg tapering over 6 months
• Type 2 (ENL - Erythema Nodosum Leprosum): Treat with Clofazimine (increased dose) ± Prednisolone ± Thalidomide

• ROM: Rifampicin 600mg + Ofloxacin 400mg + Minocycline 100mg - single dose

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Note: All content is based on current National Health Policy guidelines, NHM frameworks, and standard PSM textbook content (Park's Textbook of Preventive and Social Medicine). Drug regimens and programme details reflect guidelines current as of 2024-25. Programme figures (targets, timelines) should be cross-checked with the latest government circulars before exams as they are updated periodically.

Chapter 7: Demography & Family Planning

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LONG QUESTIONS

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1. Demographic Cycle (Demographic Transition)

Definition

Demographic Transition Theory

Five Stages of Demographic Transition

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• Both birth rate (BR) and death rate (DR) are HIGH (35-40/1000)
• Population growth is LOW/STATIC (BR ≈ DR)
• High infant mortality, short life expectancy
• Subsistence agriculture, no family planning
• Example: Pre-industrial Europe, isolated tribes

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• Birth rate remains HIGH
• Death rate begins to FALL (due to sanitation, agriculture, medicine)
• Population growth RAPID (gap between BR and DR widens)
• Natural increase accelerates
• Example: India in early 20th century, many developing countries today

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• Birth rate begins to FALL (urbanization, education, family planning)
• Death rate continues to fall (reaching low levels)
• Population growth still occurring but slowing
• Example: India currently (BR and DR both declining)

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• Both birth rate and death rate are LOW (~10-15/1000)
• Population growth stable/near zero
• Aging population
• Example: USA, UK, France in late 20th century

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• Birth rate falls BELOW death rate
• Population decline
• TFR < 2.1 (below replacement level)
• Aging crisis, shrinking workforce
• Example: Japan, Germany, some Eastern European countries

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India's Position

Key Demographic Indicators of India (SRS/NFHS-5 2019-21)

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Demographic Dividend

• Large working-age population (15-64 years) relative to dependent population
• Opportunity for economic growth
• India's "demographic dividend window" is approximately 2020-2050
• Requires investment in education, health, employment to capitalize

Population Explosion

• World population reached 8 billion (November 2022)
• India surpassed China in April 2023
• Major concern: rapid population growth straining resources

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2. IUCD (Intrauterine Contraceptive Device)

Definition

Types of IUCDs

• Lippes Loop (historical) - no longer used
• Stainless steel ring (China)

• Copper T 200 (CuT-200): Duration 3-5 years; 200 mm² copper
• Copper T 200B (CuT-200B): Modified, 3-5 years
• Copper T 380A (CuT-380A): 380 mm² copper; duration 10 years; most effective copper IUCD; most commonly used in India's National Programme
• Multiload-375 (MLCu-375): 5 years
• Nova T: Copper + silver core, 5 years

• LNG-IUS (Levonorgestrel Intrauterine System) - Mirena: 52 mg LNG; duration 5 years; reduces menstrual blood loss; also used for menorrhagia
• Progestasert: Progesterone, 1 year (older, less used)

Copper T 380A (Most Important)

• Failure rate: 0.6-0.8 per 100 woman-years (Pearl Index)
• Duration: 10 years
• Mechanism:
  1. Copper ions: Spermicidal (impair sperm motility, viability)
  2. Foreign body reaction: Uterine inflammatory response, phagocytosis of sperm
  3. Endometrial changes: Inhibit implantation
  4. Cervical mucus: Becomes hostile to sperm
  5. Tubal motility: May be altered
• Does NOT prevent ovulation primarily (unlike hormonal methods)
• Emergency use: Can be used as post-coital IUCD within 5 days - most effective emergency contraception (>99%)

Ideal Timing of Insertion

• Interval (routine): Any time during menstrual cycle if not pregnant (preferably days 1-12 of cycle)
• Post-partum: Within 48 hours (PPIUCD - Post-Partum IUCD) or after 4-6 weeks (interval)
• Post-abortion: Immediately after abortion/MTP if no infection
• Post-cesarean: Intra-cesarean IUCD insertion

PPIUCD (Post-Partum IUCD)

• Inserted within 10 minutes of placental delivery (intra-cesarean or post-vaginal)
• Or within 48 hours post-partum
• High expulsion rate compared to interval insertion
• Major initiative under RMNCH+A programme

Contraindications (Absolute)

• Pregnancy
• Unexplained vaginal bleeding
• Distorted uterine cavity (fibroids, anomalies)
• Active PID or STI
• Puerperal sepsis
• Cervical/endometrial cancer
• Known/suspected uterine malignancy
• Copper allergy / Wilson's disease (for copper IUCDs)

Advantages

• Long-acting (10 years for CuT-380A)
• Highly effective (>99%)
• Reversible - fertility returns immediately on removal
• No systemic hormonal effects (copper IUCDs)
• Cost-effective
• Suitable for breastfeeding mothers
• No user compliance required

Disadvantages / Side Effects

• Dysmenorrhea (especially first few months)
• Menorrhagia (increased menstrual bleeding/duration) - copper IUCDs
• Expulsion (5-10%)
• Pelvic inflammatory disease (if STI present at insertion)
• Ectopic pregnancy risk (if IUCD fails)
• Uterine perforation (rare, 1/1000)

IUCD in National Programme

• Free insertion at government health facilities
• Trained ANM/MO can insert
• CuT-380A: standard device used
• Antara (injectable DMPA) and Chhaya (centchroman) added as newer options
• Copper T given free of cost under National Family Planning Programme

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SHORT NOTES

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Population Pyramid

• A graphical representation of age-sex distribution of a population
• X-axis: Population (males on left, females on right)
• Y-axis: Age groups (5-year cohorts)

1. Expansive/Broad-based (Triangle): Wide base, narrow apex; high birth rate, high death rate, rapid growth; typical of developing countries (India previously)
2. Constrictive (Urn/Inverted triangle): Narrow base, wider middle; low birth rate; declining population; Japan, Germany
3. Stationary (Bell/Column): Roughly equal at all ages; stable population; neither growing nor declining

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Vital Statistics

• Collection, compilation, analysis and dissemination of data on vital events (birth, death, marriage, divorce, stillbirth)
• Source in India: Civil Registration System (CRS) - compulsory registration of births and deaths under Registration of Births and Deaths Act 1969
• Sample Registration System (SRS): Large-scale demographic survey for vital rates - most reliable source of BR, DR, IMR in India
• Census: Every 10 years (last: 2011; 2021 delayed due to COVID)
• Vital statistics indicators: CBR, CDR, IMR, MMR, TFR, NRR, life expectancy

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GFR (General Fertility Rate)

• Definition: Number of live births per 1000 women of reproductive age (15-49 years) per year
• Formula: GFR = (Live births in a year / Mid-year female population aged 15-49) × 1000
• Better than CBR as denominator restricted to females of reproductive age
• India GFR ≈ 66/1000 women aged 15-49 (NFHS-5)

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ASFR (Age-Specific Fertility Rate)

• Definition: Number of live births per 1000 women in a specific age group per year
• Formula: ASFR = (Live births to women in age group / Mid-year women in that age group) × 1000
• Calculated separately for each 5-year age group (15-19, 20-24, 25-29...45-49)
• Most refined measure of fertility
• ASFR for 15-19 years = Adolescent Fertility Rate (important indicator)

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TFR (Total Fertility Rate)

• Definition: Average number of children a woman would have if she were to pass through reproductive years (15-49) bearing children at the currently observed age-specific fertility rates
• TFR = Sum of all ASFRs × 5 (for 5-year age groups) / 1000
• Replacement level TFR = 2.1 (to maintain population size)
• India TFR (NFHS-5): 2.0 (first time below replacement level)
• TFR varies by state: Bihar highest (2.98), Sikkim lowest (1.1)
• NHM target: TFR 2.1

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NRR (Net Reproduction Rate)

• Definition: Average number of daughters that would be born to a woman passing through her reproductive life according to current ASFR and surviving according to current age-specific mortality rates
• NRR = 1: Population exactly replacing itself
• NRR > 1: Population growing
• NRR < 1: Population declining
• More accurate than TFR as it accounts for mortality
• India NRR ≈ 0.96 (below 1, indicating long-term population decline)

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GRR (Gross Reproduction Rate)

• Definition: Average number of daughters that would be born to a woman if she survived through entire reproductive period at current ASFR
• Similar to TFR but counts only female births
• GRR = TFR × proportion of female births (≈ 0.488)
• Does NOT account for mortality (unlike NRR)
• GRR > 1 does not guarantee population growth (mortality may prevent daughters from surviving to reproduce)
• NRR = GRR × probability of surviving to mean age of childbearing

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Dependency Ratio

• Definition: Ratio of dependent population (too young or too old to work) to working-age population
• Formula: Dependency Ratio = [(Population <15 + Population >64) / Population 15-64] × 100
• Child Dependency Ratio: (Pop <15 / Pop 15-64) × 100
• Old-Age Dependency Ratio: (Pop >64 / Pop 15-64) × 100
• India's dependency ratio: ~48 (declining with demographic transition)
• High dependency ratio → economic burden; Low = demographic dividend opportunity

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Sex Ratio

• Definition in India: Number of females per 1000 males
• (Note: International definition = males per 100 females)
• India Sex Ratio (Census 2011): 943 females per 1000 males
• Child Sex Ratio (0-6 years, Census 2011): 919 females per 1000 males (alarmingly low - reflects female foeticide)
• NFHS-5 sex ratio at birth: 929 females per 1000 males
• Normal biological sex ratio at birth: ~952 females per 1000 males
• Low sex ratio reflects: female foeticide, infanticide, neglect of girl child
• PCPNDT Act 1994 (amended 2003): Prohibits sex determination of foetus

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Eligible Couple

• Definition: A currently married couple where the wife is in the reproductive age group (15-44 years or 15-45 years)
• Eligible for family planning services
• Eligible Couple Register: Maintained by ANM at sub-centre
• Used to assess family planning needs, target services
• Couple Protection Rate (CPR): Percentage of eligible couples effectively protected by any contraceptive method; India CPR ≈ 67% (NFHS-5)

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Pearl Index

• Definition: Standard measure of contraceptive failure rate
• Formula: Pearl Index = (Number of failures / Total months of exposure) × 1200
  • Or: (Failures / Woman-years of exposure) × 100
• Expressed as: Number of pregnancies per 100 woman-years
• Lower Pearl Index = more effective

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Emergency Contraception

• Definition: Contraceptive methods used after unprotected sexual intercourse to prevent pregnancy
• Also called "morning after pill" or post-coital contraception
• NOT for regular use

1. Levonorgestrel (LNG) EC:
   • "i-pill," "Plan B," "Unwanted 72"
   • 1.5 mg LNG as single dose (or 0.75 mg × 2, 12 hours apart)
   • Within 72 hours (more effective sooner)
   • Efficacy: 85-89% (reduces pregnancy risk by 85%)
   • Mechanism: Delays/inhibits ovulation; may affect implantation
   • Available over the counter in India
2. Ulipristal Acetate (UPA):
   • "EllaOne"
   • 30 mg single dose
   • Effective up to 120 hours (5 days)
   • More effective than LNG especially 72-120 hours
   • Selective Progesterone Receptor Modulator (SPRM)
3. Combined OCP - Yuzpe Method:
   • High-dose combined OCPs in 2 doses 12 hours apart
   • Less effective, more side effects; rarely used now
4. Copper IUCD (CuT-380A):
   • Most effective EC (>99%)
   • Within 5 days of unprotected intercourse
   • Can continue as regular contraception for 10 years
   • Preferred for women wanting ongoing contraception

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Copper T (CuT-380A) - Additional Details

• Copper: 380 mm² surface area
• Duration: 10 years
• Pearl Index: 0.6-0.8
• Inserted at any time in menstrual cycle (preferably days 1-12), post-partum within 48h, post-abortion
• Available free at government health centres
• Threads visible at follow-up (4-6 weeks after insertion, then annually)

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Antara Programme

• Antara = Injectable contraceptive programme (DMPA - Depot Medroxyprogesterone Acetate)
• Launched under National Family Planning Programme (2016)
• Drug: DMPA 150 mg IM injection
• Frequency: Every 3 months (13 weeks)
• Mechanism: Inhibits ovulation (LH surge suppression), thickens cervical mucus
• Highly effective: Pearl Index ~0.3
• Advantages: Injected by ANM/nurse, no daily compliance, discreet, safe for breastfeeding (after 6 weeks)
• Disadvantages: Irregular bleeding/spotting, amenorrhea, delayed return of fertility (3-18 months after last injection), weight gain, no STI protection
• Available free at government health facilities
• Antara brand = DMPA 150 mg in India's government programme

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Mala N (Oral Contraceptive Pill)

• Mala N = Combined oral contraceptive pill provided free under India's National Family Planning Programme
• Composition: Norethisterone 1 mg + Ethinyl Estradiol 0.035 mg
• 28-pill pack: 21 active pills + 7 iron tablets (ferrous fumarate)
• Mechanism: Inhibits ovulation, thickens cervical mucus, thins endometrium
• Start: Day 1 of menstrual cycle (Sunday start also acceptable)
• Quick Start: Can start any day if reasonably certain not pregnant
• Take daily at same time; if missed 1 pill (<24 hours): take immediately; if missed 2+ pills: take 2 pills and use backup
• Side effects: Nausea, breast tenderness, spotting (initial), headache; rare - DVT, stroke (especially smokers >35)
• Available at sub-centres, PHCs free of cost
• Pearl Index: 0.1-1 (perfect use), 3-8 (typical use)

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Mala D

• Mala D = Another brand of combined OCP in India's programme (earlier version)
• Composition: Norgestrel 0.5 mg + Ethinyl Estradiol 0.05 mg (higher estrogen than Mala N)
• 21-pill pack (no iron tablets)
• Being phased out/replaced by Mala N in government programme
• Mechanism same as Mala N
• Higher estrogen dose = more side effects; hence Mala N preferred

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Barrier Methods

• Most widely available barrier method
• Material: Latex (most common), polyurethane (for latex allergy), polyisoprene
• Dual protection: Prevents pregnancy AND STIs (including HIV)
• Pearl Index: 2-12 (typical use)
• Nirodh = government brand condom distributed free in India
• Must use every time, correctly (leave space at tip, roll on before any contact, use correct size)

• Inner ring and outer ring, polyurethane
• Can be inserted up to 8 hours before intercourse
• Pearl Index: 5-21 (typical use)
• Less widely used in India

• Dome-shaped rubber/silicone cup
• Covers cervix + upper vagina
• Used with spermicide
• Insert up to 6 hours before, leave in 6 hours after
• Pearl Index: 6 (perfect), 12-18 (typical)
• Requires fitting by healthcare provider

• Smaller than diaphragm, fits directly on cervix
• Pearl Index varies by parity
• Less common in India

• Nonoxynol-9 (most common chemical spermicide)
• Forms: cream, foam, jelly, film, suppositories
• Used alone (Pearl Index ~18) or with other methods
• Do NOT protect against HIV (may increase risk with frequent use)

• Contains spermicide, foam cervical barrier
• Less used in India

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Sterilization

• Most common female sterilization method
• Approaches: Laparoscopic (most common), mini-laparotomy (post-partum), open laparotomy
• Methods: Falope ring, Hulka clip, Filshie clip, Pomeroy technique (cutting and ligating), Irving technique, Fimbriectomy, Salpingectomy
• Minilaparotomy + Pomeroy: Most common technique post-partum
• Timing: Post-partum (Interval: 6 weeks after delivery), Post-abortion (immediately or within 7 days), Interval (any time)
• Pearl Index: 0.5/100 woman-years
• Failure: Ectopic pregnancy risk if failure occurs
• CCSQ (Camp and Clinical Services Quality) - quality assurance
• ASHA incentive: Rs. 300 for motivating sterilization acceptance

• No-Scalpel Vasectomy (NSV): Preferred technique in India
  • Small puncture in scrotal skin (no incision)
  • Less complications, faster recovery
  • Takes 10-15 minutes under local anaesthesia
  • Patient walks home
• Conventional vasectomy: Small incision, less commonly done
• Pearl Index: 0.1/100 woman-years (most effective contraceptive)
• Post-vasectomy: Semen analysis after 3 months/15-20 ejaculations to confirm success
• Failure: Recanalization (0.05%)
• Advantages over tubectomy: Simpler, cheaper, safer (outpatient, local anaesthesia), fewer complications
• Azoospermia confirmed before declaring success
• Under National Programme: Free at government facilities + cash incentive for acceptors

• Both tubectomy and vasectomy reversal possible but success rates limited (vasectomy reversal 40-70% depending on interval)

• Female sterilization >> Male sterilization (gender imbalance)
• Male sterilization <10% of all sterilizations (should be encouraged)
• Quality of care issues historically
• FOGSI-NHM protocols for quality assurance

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Important exam figures to remember: India TFR = 2.0 (NFHS-5); Replacement TFR = 2.1; CuT-380A duration = 10 years; LNG EC effective up to 72 hours; Copper IUCD EC up to 5 days; Vasectomy Pearl Index = 0.1; DMPA (Antara) every 3 months; Mala N = Norethisterone 1 mg + EE 0.035 mg.

Chapter 8: Preventive Obstetrics, Paediatrics & Geriatrics

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LONG QUESTIONS

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1. ANC (Antenatal Care)

Definition

Objectives of ANC

• Promote, protect, and maintain maternal health
• Detect and treat complications early
• Prepare the mother physically and psychologically for delivery
• Prepare for newborn care and breastfeeding
• Reduce MMR and IMR

ANC Schedule

• More contacts = better outcomes
• First contact: <12 weeks

Components of ANC ("3T + ANC")

• Obtain obstetric history, medical/surgical history, family history
• Physical examination: weight, height, BP, pallor, oedema, fundal height
• Obstetric examination: presentation, lie, FHR

• 11-14 weeks: Dating scan + NT (nuchal translucency) for Down syndrome
• 18-20 weeks: Anomaly scan (TIFFA - Targeted Imaging for Fetal Anomalies)
• 28-32 weeks: Growth scan, presentation
• 36+ weeks: Presentation, placenta, liquor

• In India: Td vaccine (replacing TT alone since 2023)
• Neonatal tetanus prophylaxis: Td given to mother passes IgG to fetus

• Folic acid: 5 mg/day from preconception to 12 weeks (periconceptional - prevents NTDs)
• IFA tablets: 100 mg elemental iron + 500 mcg folic acid daily from 2nd trimester for 180 days (or from first ANC visit)
• Calcium supplementation: 500 mg twice daily from 2nd trimester - prevents pre-eclampsia

• Age <18 or >35 years
• Grand multipara (>4)
• Height <145 cm (small pelvis risk)
• Weight <45 kg or >80 kg
• Anaemia (Hb <11g/dL in 1st trimester)
• Hypertension (BP ≥140/90)
• Gestational diabetes
• Previous bad obstetric history (stillbirth, NND, repeated abortions)
• Previous C-section
• Multiple pregnancy, malpresentation
• Medical disorders (heart, kidney, thyroid)

• Nutrition in pregnancy
• Danger signs (see short notes)
• Birth preparedness: 3 delays prevention
• Breastfeeding promotion
• Contraception counseling
• HIV/AIDS counseling

• Deworming: Single dose Albendazole 400 mg in 2nd trimester (safe after 12 weeks)

Weight Gain in Pregnancy

• Total recommended weight gain: 10-12 kg (BMI normal)
• 1st trimester: ~1-2 kg
• 2nd and 3rd trimesters: ~0.4-0.5 kg/week
• Underweight women: 12.5-18 kg
• Overweight women: 7-11.5 kg
• Obese women: 5-9 kg

PMSMA (Pradhan Mantri Surakshit Matritva Abhiyan)

• Free comprehensive ANC by specialists on 9th of every month
• High-risk pregnancy identification and care planning
• "3 Cs": Checkup, Certification (high-risk), Care plan

Birth Preparedness Plan (3 As)

• Arrangement for funds
• Arrangement for transport
• Arrangement for accompanying person (skilled birth attendant)
• Plus: Decision-maker, blood donor identification

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2. PNC (Postnatal Care)

Definition

Why Important

PNC Schedule (WHO 2022 / India)

Maternal PNC Care

• Monitor for PPH (most common cause of maternal death): uterine tone, blood loss
• BP, pulse every 15 minutes in 1st hour
• Fundal massage to prevent atonic PPH
• Early breastfeeding initiation within 1 hour
• Uterotonic agents: Oxytocin 10 IU IM immediately after delivery of baby (AMTSL - Active Management of Third Stage of Labour)

• Involution of uterus (1 cm/day descent, non-palpable by 12 days)
• Lochia assessment: rubra (first 3-4 days), serosa (day 5-9), alba (day 10 onwards)
• Breastfeeding support
• Perineal care (episiotomy/tear)
• Bowel and bladder care
• Iron and calcium supplementation continuation

• Contraceptive counseling and provision (LAM, OCP after 6 weeks, PPIUCD if not already done)
• Immunization: Baby's BCG, OPV0, Hepatitis B (birth dose) before discharge
• Danger signs counseling

• Complete recovery check
• Family planning (IUCD insertion if not done, sterilization discussion)
• Baby's vaccination status
• Nutritional assessment

Newborn PNC Care

• ENBC (Essential Newborn Care - see newborn section)
• Breastfeeding: exclusive breastfeeding for 6 months
• Eye care, cord care
• Vitamin K 1 mg IM
• Birth dose vaccines: BCG + OPV0 + Hep B0
• Warmth (KMC if LBW)
• Danger signs: fast breathing, fever/hypothermia, poor feeding, convulsions, jaundice

JSSK Entitlements (postnatal)

• Free stay: 48 hours (normal delivery), 72 hours (C-section)
• Free diet, free drugs, free transport home

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3. IMR (Infant Mortality Rate)

Definition

IMR = (Deaths of infants <1 year / Live births in same year) × 1000

Components of IMR

• Early NMR: Deaths in 0-6 days (Day 0-6)
• Late NMR: Deaths in 7-27 days

India's IMR Figures (SRS 2020)

• SDG target: U5MR <25 by 2030
• NHM target: IMR <25/1000 live births

Causes of Infant Mortality

1. Prematurity/LBW (most common overall)
2. Birth asphyxia
3. Sepsis/Infections
4. Congenital anomalies
5. Hypothermia

1. Diarrhoeal diseases
2. ARI/Pneumonia
3. Malnutrition
4. Vaccine-preventable diseases
5. Accidents

Uses of IMR

• Sensitive indicator of overall health status of a community
• Reflects: maternal health, nutritional status, socioeconomic conditions, healthcare availability
• Used internationally for comparing health status between countries
• "Best single index of socioeconomic development and healthcare"

Factors Affecting IMR

• Poverty, malnutrition
• Low birth weight
• Illiteracy of mother
• Lack of antenatal care
• Poor perinatal care
• Inadequate immunization
• Overcrowding, poor sanitation
• Early marriage, teenage pregnancy

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4. MMR (Maternal Mortality Rate/Ratio)

Definition

Note: MMR in most usage refers to the Ratio (per 100,000 live births)

India MMR

• SRS 2018-20: 97/100,000 live births (below 100 for first time)
• SDG target: <70/100,000 by 2030
• NHM target: <100/100,000
• State variation: Kerala 19 (lowest) to Assam 195 (highest)

Classification of Maternal Deaths

1. Haemorrhage (most common - 38%): PPH, APH
2. Hypertensive disorders (pre-eclampsia, eclampsia) - 20%
3. Sepsis - 11%
4. Obstructed/prolonged labour - 9%
5. Complications of abortion - 8%
6. Embolism

• Anaemia (most important indirect cause in India)
• Heart disease, malaria, HIV
• Pre-existing medical conditions aggravated by pregnancy

Lifetime Risk of Maternal Death

Maternal Death Review (MDR)

• Mandatory under NHM
• Every maternal death reviewed at facility + community level
• Identify delays (Three Delays), corrective actions
• MDSR (Maternal Death Surveillance and Response) - WHO framework

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5. Low Birth Weight (LBW)

Definition

• Defined by WHO
• Weighed within first hour of birth (before significant weight loss)

Classification

Types (by cause)

1. Preterm (premature): Born before 37 completed weeks of gestation but appropriate weight for gestational age (AGA)
2. SGA (Small for Gestational Age): Born at term but weight below 10th percentile for gestational age = IUGR (Intrauterine Growth Restriction)
3. Both: Preterm + SGA

• Extreme preterm: <28 weeks
• Very preterm: 28-32 weeks
• Moderate/Late preterm: 32-37 weeks

Causes

• Malnutrition, anaemia
• Teenage pregnancy, grand multiparity
• Infections (UTI, malaria, syphilis, TORCH)
• Hypertension, pre-eclampsia
• Smoking, alcohol, drug abuse
• Short inter-pregnancy interval
• Socioeconomic factors (poverty)

• Multiple pregnancy
• Congenital anomalies
• Chromosomal disorders

• Placental insufficiency
• Placenta praevia, abruption

Complications of LBW

• Hypothermia (poor thermoregulation)
• Hypoglycemia
• Respiratory Distress Syndrome (RDS) - especially in preterm
• Apnoea of prematurity
• Necrotizing enterocolitis (NEC)
• Intraventricular haemorrhage (IVH)
• Sepsis
• Jaundice
• Feeding difficulties
• Long-term: Cerebral palsy, cognitive impairment, metabolic syndrome in adulthood (Barker hypothesis)

India's LBW Prevalence

• ~18% of births in India are LBW (NFHS-5)
• NHM target: Reduce LBW from 18% to 15%
• One of highest LBW rates globally

Management of LBW

1. KMC (Kangaroo Mother Care): Skin-to-skin contact, temperature regulation, promotes breastfeeding
2. SNCU: For sick/VLBW (see Ch6)
3. NBSU: For moderately sick/LBW
4. Feeding: Breast milk preferred; expressed breast milk via NG tube if needed
5. Prevention of hypothermia: Warm room, KMC, wrapping
6. Prevention of infection: Hand hygiene, aseptic technique
7. Prevention of hypoglycemia: Early feeds
8. Phototherapy: For neonatal jaundice

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6. Perinatal Mortality

Definition

Perinatal Period Definitions

• WHO: 22 completed weeks of gestation (when birth weight ≥500 g) to 7 completed days after birth
• India (Statistical definition): 28 weeks of gestation to 7 days after birth

Perinatal Mortality Rate (PMR)

PMR = [(Stillbirths after 28 weeks + Deaths in first 7 days) / (Live births + Stillbirths after 28 weeks)] × 1000

Components

1. Stillbirth Rate (SBR): Stillbirths per 1000 total births
   • Antepartum stillbirth: Before onset of labour
   • Intrapartum stillbirth: During labour (preventable with skilled attendance)
2. Early Neonatal Death Rate (ENDR): Deaths in 0-6 days per 1000 live births

Causes

• IUGR, fetal anomalies
• Placental insufficiency
• Pre-eclampsia, diabetes
• Infections (malaria, syphilis)
• Cord accidents

• Birth asphyxia (most common intrapartum cause)
• Obstructed labour
• Cord prolapse
• Trauma

• Prematurity/LBW
• Birth asphyxia
• Sepsis
• Congenital anomalies
• Hypothermia

Prevention

• Skilled birth attendance
• EmOC (Emergency Obstetric Care)
• ANC for high-risk detection
• Fetal monitoring during labour
• Neonatal resuscitation training (NRP/ENBC)
• KMC, SNCU for LBW/preterm

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7. IMNCI

• Feeding Assessment at 2 months-5 years visit: Assess breastfeeding, complementary feeding, dietary history
• IMCI "F-words": Feed, Fluid, Follow-up, Return immediately
• ORT: Oral Rehydration Therapy - cornerstone of diarrhoea management in IMCI
• RUTF (Ready-to-Use Therapeutic Food): Plumpy'Nut for SAM in community management
• Key danger signs (2 months-5 years):
  • Not able to drink/breastfeed
  • Vomits everything
  • Convulsions
  • Abnormally sleepy/difficult to awaken

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8. School Health

Definition

Importance

• Children 6-18 years = 25% of population in India
• School = ideal setting for health promotion (captive audience)
• Health habits formed in childhood last lifetime
• Early detection of conditions treatable at low cost

School Health Services (Components)

• Annual health examination of all school children
• Under RBSK: 2 health teams per block (mobile)
• Examine for: nutritional status, growth, vision, hearing, dental caries, skin diseases, mental health, locomotor problems, cardiac defects
• Record in MCP card (up to 5 years); school health record thereafter

• Spectacle provision for refractive errors (free under NPCDCS/NPCBVI)
• Dental treatment
• Referral for deformities, congenital defects (RBSK-DEIC)
• Treatment of worm infestations

• Immunization in schools
• Management of outbreaks (measles, chickenpox)
• Exclusion of infectious children

• School building: Ventilation, lighting, drainage, toilets (separate for boys/girls)
• Water supply: Safe drinking water
• Sanitation: Adequate latrines (1 per 30 boys, 1 per 20 girls)
• Seating: Correct furniture ergonomics, adequate space per child
• Playgrounds: Adequate space for physical activity
• Noise levels

• Mid-Day Meal: PM POSHAN scheme - free cooked meal (described in Ch6)
• Iron and Folic Acid supplementation (WIFS)
• Biannual deworming (Albendazole)
• School garden for nutrition education

• School mental health programme (under NMHP/DMHP)
• Counselling services
• Stress, bullying, substance abuse prevention
• Life skills education

• Physical education classes
• Sports facilities
• Health education (nutrition, hygiene, puberty)
• Yoga

• First aid box in every school
• Teachers trained in basic first aid

School Health Programme (under RBSK)

• 2 Mobile Health Teams (MHT) per block: one for 0-6 years (AWC/community), one for 6-18 years (schools)
• Annual screening of all children 6-18 years in government schools
• Referral to DEIC for confirmatory diagnosis and management
• Free treatment for 30 conditions

National School Health Policy

• School children 6-14 years covered under RTE (Right to Education Act 2009)
• Sarva Shiksha Abhiyan (SSA) / Samagra Shiksha
• Kasturba Gandhi Balika Vidyalayas - residential schools for girls

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9. SAM (Severe Acute Malnutrition)

Definition (WHO/UNICEF 2009)

• MUAC (Mid-Upper Arm Circumference) < 11.5 cm (in 6-59 month olds), OR
• WHZ (Weight-for-Height Z-score) < -3 SD (severe wasting), OR
• Bilateral pitting oedema (kwashiorkor/marasmic-kwashiorkor)

MAM (Moderate Acute Malnutrition)

• MUAC 11.5-12.5 cm
• WHZ -2 to -3 SD

India Statistics

• ~7.7% of children under 5 are severely wasted (NFHS-5)
• India bears ~33% of global SAM burden
• SAM children have 9× higher risk of death than well-nourished children

Identification

• MUAC tape: Simple, reliable, can be done by community health workers
• MUAC <11.5 cm = SAM (red zone); 11.5-12.5 = MAM (yellow); >12.5 = normal (green)
• WHZ on growth chart
• Oedema check: Thumb pressure on dorsum of foot for 3 seconds - pitting = oedema

SAM with Complications vs. Uncomplicated SAM

• Medical complications: severe oedema, anorexia (fails appetite test), medical illness (pneumonia, severe dehydration, high fever, hypoglycemia)
• Appetite test: Offer RUTF - if child refuses = complicated SAM

Facility-Based Management (NRC - Nutritional Rehabilitation Centre)

• F-75: 75 kcal/100 ml; low protein - stabilization phase
• F-100: 100 kcal/100 ml; high protein - rehabilitation phase
• RUTF (Ready-to-Use Therapeutic Food): e.g., Plumpy'Nut - peanut-based paste; 500 kcal/sachet; used in community management
• India: Bal Shakti = RUTF formulation

• Minimum 2-week admission
• Target weight gain: ≥15 g/kg/day in rehabilitation phase
• Discharge criteria: MUAC ≥12.5 cm or WHZ ≥-2 SD, resolution of oedema, appetite restored, medical complications resolved
• Follow-up: After discharge, ASHA/AWW follow-up for next 3 months

Community Management (CMAM)

• For SAM without complications
• RUTF provided as home-based therapeutic food
• Monthly follow-up
• ASHA/AWW track

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10. Geriatric Health Problems

Demographics

• India: ~104 million elderly (>60 years); ~9% of population
• UN definition of elderly: ≥60 years (developing countries) or ≥65 years (developed)
• Projected: 316 million by 2050
• Oldest old: >80 years (fastest growing segment)

Characteristics of Geriatric Health

• Multiple chronic diseases (multimorbidity)
• Polypharmacy
• Functional decline
• Frailty syndrome
• Cognitive impairment
• Social isolation
• Falls and fractures
• Sensory impairment (vision, hearing)

Common Health Problems

• Hypertension (most common - 60% of elderly)
• Ischemic heart disease
• Heart failure
• Atrial fibrillation
• Isolated systolic hypertension

• Diabetes mellitus type 2
• Dyslipidemia
• Hypothyroidism
• Osteoporosis (bone mineral density loss)

• Dementia (Alzheimer's disease most common)
• Parkinson's disease
• Cerebrovascular accident (stroke)
• Depression (most common psychiatric disorder in elderly)
• Anxiety
• Delirium (acute confusion - common in hospitalized elderly)

• Osteoarthritis (most common joint disease)
• Rheumatoid arthritis
• Osteoporosis → fractures
• Falls: 30% of elderly >65 fall each year; hip fracture = major complication
• Sarcopenia (muscle loss)

• Presbyopia (age-related vision loss)
• Cataracts (most common cause of blindness in elderly)
• Glaucoma
• Age-related macular degeneration (AMD)
• Presbycusis (age-related hearing loss)

• Lung, colorectal, prostate, breast cancers increase with age
• Oral cancers (tobacco-related)

• Benign Prostatic Hyperplasia (BPH) in males
• Urinary incontinence (stress, urge, overflow)
• Recurrent UTIs

• Constipation
• Malnutrition, malabsorption
• Dysphagia
• Peptic ulcer disease

• Immobility
• Instability (falls)
• Intellectual impairment (dementia)
• Incontinence (urinary/faecal)
• Iatrogenic illness (polypharmacy, adverse drug effects)
• Some add: Malnutrition, Abuse, Depression, Sensory impairment

• Physical, emotional, financial, sexual abuse and neglect
• Often by family members
• Maintenance and Welfare of Parents and Senior Citizens Act 2007 - legal protection

NPHCE (National Programme for Health Care of the Elderly)

• Wednesday OPD for elderly at PHC level
• Geriatric ward at District Hospital
• Regional Geriatric Centres at medical colleges

Comprehensive Geriatric Assessment (CGA)

• Functional status: ADL (Activities of Daily Living - Barthel Index), IADL
• Cognitive: MMSE (Mini Mental State Examination), MoCA
• Affective: GDS (Geriatric Depression Scale)
• Physical: Gait, balance (Timed Up and Go test), fall risk
• Nutritional: MNA (Mini Nutritional Assessment)
• Social: Social support, living conditions, caregiver assessment

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SHORT NOTES

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Diet in Pregnancy

• Green leafy vegetables (iron, folate)
• Pulses, legumes (protein)
• Milk, dairy (calcium, protein)
• Eggs, meat/fish (protein, iron)
• Citrus fruits (Vitamin C enhances iron absorption)
• Iodized salt

• Raw/undercooked meat, fish (Listeria, Toxoplasma)
• Unpasteurized milk (Brucella, Listeria)
• Excess Vitamin A (liver/supplements - teratogenic)
• Alcohol (Fetal Alcohol Syndrome)
• High mercury fish (tuna - neurotoxic)
• Caffeine >200 mg/day

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KMC (Kangaroo Mother Care)

• Skin-to-skin contact between LBW/preterm baby and mother (or father)
• Baby placed in "kangaroo position" - upright on mother's chest between breasts
• Continuous 24 hours/day, started in SNCU, continued at home
• Eligibility: Birth weight <2000 g, clinically stable (no IV lines, oxygen, severe illness)

• Thermoregulation (maintains 36.5-37.5°C)
• Promotes breastfeeding and breast milk production
• Reduces infection risk
• Reduces hospital stay
• Reduces neonatal mortality by 40% in LBW
• Neurodevelopmental benefits
• Strengthens mother-baby bonding
• Reduces pain

• Vertical (frog position), head turned to one side
• Covered with cloth to maintain warmth
• Breathing monitored visually

1. Kangaroo position (skin-to-skin)
2. Kangaroo nutrition (exclusive breast milk)
3. Kangaroo support (early discharge with adequate support)

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Growth Chart

• Graphical representation of a child's physical growth over time
• Used to monitor growth, identify growth faltering early, assess nutritional status

• Based on children raised in optimal conditions worldwide
• Used globally as reference
• Indian Academy of Pediatrics (IAP) endorses WHO 2006 standards

• Weight for Age (WFA) - reflects current and past nutrition
• Height/Length for Age (HFA) - reflects chronic malnutrition (stunting)
• Weight for Height/Length (WFH) - reflects acute malnutrition (wasting)
• Head Circumference for Age
• BMI for Age

• MCP Card (Mother and Child Protection Card): Contains growth chart (0-5 years)
• Used at AWC, PHC, immunization sessions

• Upward slope = adequate growth
• Flat slope = growth faltering (investigate)
• Downward slope = weight loss (serious)

• 50th percentile = median
• <3rd percentile = below normal (investigation needed)

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MCP Card (Mother and Child Protection Card)

• Issued to every pregnant woman at time of ANC registration
• Maintained by the woman/family
• Contents:
  • Mother's ANC record: BP, weight, Hb, urinalysis, ultrasound dates, IFA tablets, TT/Td immunization
  • Delivery details: type, complications
  • Child's growth chart (0-5 years)
  • Child's immunization record (UIP schedule)
  • HBNC visits by ASHA
  • Family planning record
• Pink book in most states
• Used as a communication tool between health workers, facility, and family

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BFHI (Baby-Friendly Hospital Initiative)

• Launched jointly by WHO and UNICEF in 1991
• To protect, promote, and support breastfeeding globally
• Hospitals that comply with "10 Steps to Successful Breastfeeding" are designated "Baby Friendly"

1. Comply fully with the International Code of Marketing of Breast-milk Substitutes
2. Have a written infant feeding policy; routinely communicate to staff and parents
3. Ensure staff have sufficient knowledge, competence and skills to support breastfeeding
4. Discuss importance and management of breastfeeding with pregnant women and their families
5. Support mothers to initiate and maintain breastfeeding and manage common difficulties
6. Do not provide breastfed newborns with food or fluids other than breast milk (unless medically indicated)
7. Enable mothers and infants to remain together 24 hours a day (rooming-in)
8. Support mothers to recognize and respond to infant feeding cues
9. Counsel mothers on the use and risks of feeding bottles, teats and pacifiers
10. Coordinate discharge so that parents and infants have timely access to ongoing support

• BFHI cells at state and district level
• Government facilities being made BFHI compliant

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NRC (Nutritional Rehabilitation Centre)

• Facility-based management of SAM children with medical complications
• Under NHM/RMNCH+A at CHC and District Hospital level
• 10-bed ward (standard) for children aged 6 months-5 years with SAM + complications

• Medical management (antibiotics, IV fluids, electrolytes)
• Therapeutic feeding (F-75, F-100 or RUTF)
• Micronutrient supplementation
• Nutrition counseling to mother
• Stimulation and play therapy
• Mother training for home management

• Anorexia (fails appetite test with RUTF)
• Severe oedema (++/+++)
• Medical complications (pneumonia, dehydration, high fever, altered consciousness, hypoglycemia)

• MUAC ≥12.5 cm or WHZ ≥-2 SD
• No oedema for 2 consecutive days
• Good appetite, eating well
• Alert, active, no fever
• Minimum 2-week stay completed

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Danger Signs in Pregnancy

1. Vaginal bleeding at any time (antepartum haemorrhage - placenta praevia, abruption; or miscarriage)
2. Severe headache with blurred vision (pre-eclampsia/eclampsia)
3. Fits/convulsions (eclampsia)
4. Swelling of face, hands, feet (pre-eclampsia)
5. High fever (infection - UTI, malaria, sepsis)
6. Severe abdominal pain (abruption, preterm labour, appendicitis)
7. No fetal movements / decreased fetal movements (<10 movements in 12 hours from 28 weeks)
8. Leaking of fluid/water from vagina (PROM - Premature Rupture of Membranes)
9. Difficulty breathing (anaemia, heart disease, pulmonary embolism)
10. Pallor, dizziness, fainting (severe anaemia, haemorrhage)
11. Offensive vaginal discharge with fever (infection)
12. Vomiting with inability to keep fluids down (hyperemesis gravidarum)

• D - Dizziness, decreased fetal movement
• A - Abdominal pain, APH
• N - No fetal movement
• G - Giddiness (fainting), Grip pressure headache
• E - Eclampsia (fits), Edema
• R - Rupture of membranes

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Toxaemia of Pregnancy (Hypertensive Disorders of Pregnancy)

1. Gestational Hypertension: BP ≥140/90 after 20 weeks; no proteinuria; resolves by 12 weeks postpartum
2. Pre-eclampsia: BP ≥140/90 after 20 weeks + proteinuria ≥300 mg/24h (or protein:creatinine ≥0.3 or dipstick ≥1+); or severe features without proteinuria
3. Eclampsia: Pre-eclampsia + seizures (tonic-clonic convulsions)
4. HELLP Syndrome: Haemolysis + Elevated Liver enzymes + Low Platelets; variant of severe pre-eclampsia
5. Chronic Hypertension: BP ≥140/90 before 20 weeks or pre-existing
6. Chronic Hypertension + superimposed Pre-eclampsia

• BP ≥160/110
• Proteinuria >5g/24h
• Headache, visual disturbances, epigastric pain
• Pulmonary oedema
• Thrombocytopenia (<100,000/μl)
• Elevated creatinine

• Moderate/severe: MgSO₄ (Magnesium sulphate) for seizure prophylaxis and treatment
  • Loading: 4g IV slow + 5g IM each buttock
  • Maintenance: 5g IM every 4 hours (Pritchard regimen)
  • OR: 4g IV + 1g/hour IV infusion (Zuspan regimen)
• Anti-hypertensives: Hydralazine IV, Labetalol IV, Nifedipine oral
• Definitive treatment: Delivery (fetus + placenta)
• Calcium supplementation in ANC reduces pre-eclampsia risk by 50%

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NPHCE (National Programme for Health Care of the Elderly)

• Launched 2010-11 under NHM
• Wednesday dedicated elderly OPD at PHC
• 10-bed geriatric ward at District Hospital
• Day Care Centre at DH
• Regional Geriatric Centre at Medical Colleges (30 beds)
• NPHCE services: Free medical care, physiotherapy, counselling, geriatric rehabilitation, palliative care
• National Policy on Older Persons (NPOP) 1999: Policy framework for elderly welfare
• Maintenance and Welfare of Parents and Senior Citizens Act 2007: Legal obligation of children to maintain parents/senior citizens; Maintenance Tribunal

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Key numbers to remember: IMR India = 35; NMR = 20; MMR = 97; LBW = <2500g; SAM MUAC <11.5 cm; F-75 stabilization → F-100 rehabilitation; MgSO₄ loading 4g IV + 5g IM (Pritchard); KMC reduces neonatal mortality by 40% in LBW; TFR India = 2.0.

Chapter 9: Health Care of the Community

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LONG QUESTIONS

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1. Primary Health Care (PHC as a Concept)

Historical Background

• International Conference on Primary Health Care, Alma-Ata, USSR (now Almaty, Kazakhstan)
• September 6-12, 1978
• Sponsored by WHO and UNICEF
• 134 countries + 67 international organizations participated
• Produced the Alma-Ata Declaration - landmark document in global health

"Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination."

• First International Conference on Health Promotion, Ottawa, Canada
• Defined Health Promotion as the process of enabling people to increase control over, and to improve, their health
• Ottawa Charter prerequisites for health: Peace, shelter, education, food, income, stable ecosystem, sustainable resources, social justice and equity

• Global Conference on PHC, Astana, Kazakhstan (40 years after Alma-Ata)
• Reaffirmed commitment to PHC
• 4 commitments:
  1. Bold political choices for health
  2. Build sustainable PHC
  3. Empower individuals and communities
  4. Align stakeholder support to national policies

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Elements of Primary Health Care (8 Essential Elements)

1. M - Maternal and child health care, including family planning
2. E - Education about prevailing health problems and methods of preventing/controlling them
3. A - Adequate safe water supply and basic sanitation
4. S - Safe food supply and proper nutrition
5. C - Control of locally endemic diseases
6. H - Health education to community
7. I - Immunization against major infectious diseases
8. D - Diagnosis and treatment of common diseases and injuries
9. E - Essential drugs provision

• Sanitation and water
• Appropriate treatment of common illness
• Food and nutrition
• Education
• MCH + Family Planning
• Immunization
• Disease control (endemic)

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Principles of PHC (5 Principles)

1. Equitable Distribution: Health services available to all, especially underserved, rural, poor - reducing inequities between urban/rural, rich/poor
2. Community Participation: Active involvement of community in planning, implementation, monitoring of health services; not passive recipients
3. Intersectoral Coordination: PHC cannot be provided by health sector alone; requires collaboration with agriculture, education, water, sanitation, social welfare, housing
4. Appropriate Technology: Technology appropriate to local needs, scientifically sound, socially acceptable, affordable - not necessarily high-tech
5. Decentralization: Decision-making and resource allocation closer to the people; district-level planning

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Levels of Health Care

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2. Sub-Centre (SC)

Definition

Population Norm

• Plain areas: 1 Sub-centre per 5,000 population
• Hilly/Tribal/Difficult areas: 1 Sub-centre per 3,000 population

Staff (IPHS norms - revised 2012)

• ANM is the key frontline worker at Sub-centre
• Male Health Worker handles malaria, sanitation, environment
• Health Assistant Female (LHV - Lady Health Visitor) supervises 6 sub-centres
• Health Assistant Male (Health Inspector) supervises 6 sub-centres

Functions of Sub-Centre (ANM's responsibilities)

• ANC registration, examination, immunization (TT/Td)
• Conducting normal deliveries (SBA trained)
• Postnatal care, HBNC
• Newborn care, breastfeeding promotion
• Family planning services: IUD insertion (if trained), oral pills, condoms, referral for sterilization

• Immunization (UIP vaccines) - Wednesday immunization day
• Growth monitoring (NWRS - nutrition weight recording session)
• IMNCI first-level care
• Vitamin A prophylaxis
• Deworming

• Malaria: slide collection, RDT, reporting
• TB: sputum collection, DOTS delivery, contact tracing
• Leprosy: case detection, MDT delivery
• Other communicable disease surveillance

• Safe water source monitoring
• Latrine construction promotion
• Sanitation surveys

• IEC/BCC activities
• VHSNC meetings (Village Health, Sanitation and Nutrition Committee)

• Eligible couple register
• Antenatal register
• Child welfare register
• Death/birth register
• Stock register

Untied Fund

• Rs. 10,000 per sub-centre per year (NHM)
• Discretionary spending on local health needs
• Managed by ANM + VHSNC

VHSNC (Village Health Sanitation and Nutrition Committee)

• At village level (Gram Panchayat/revenue village)
• Chaired by Pradhan (village head) or elected member
• Secretary: ASHA
• Members: AWW, ANM, school teacher, ASHA, elected woman representative
• Functions: Plan, monitor local health activities; manage untied fund (Rs. 10,000/village/year)

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3. PHC (Primary Health Centre)

Definition

Population Norm

• Plain areas: 1 PHC per 30,000 population
• Hilly/Tribal/Difficult areas: 1 PHC per 20,000 population

Staff (IPHS norms)

Services (24×7 PHC under NHM)

• OPD services: Diagnosis and treatment of common illnesses
• Maternal health: ANC, delivery (normal), PNC
• Child health: Immunization, IMNCI, nutrition
• Family planning: IUD insertion, distribution of contraceptives, referral for sterilization
• Inpatient: 6 beds (under NHM - 24×7 delivery)
• Laboratory: Basic tests (Hb, urine, malaria smear, sputum, blood glucose, CBC)
• Referral: To CHC/DH for complicated cases
• Disease surveillance and control: DOTS, malaria, leprosy, surveillance
• IEC and health education

Key Features under NHM

• 24×7 PHC: Selected PHCs upgraded for round-the-clock delivery services
• Rogi Kalyan Samiti (RKS): Hospital management committee; manages user fee funds
• Untied funds: Rs. 25,000/year for PHC
• Annual Maintenance Grant: Rs. 50,000/year
• AYUSH Integration: AYUSH doctor/pharmacist posted at PHC
• Mobile Medical Unit (MMU): Visits difficult/remote areas

PHC as Health and Wellness Centre (HWC - AB-HWC)

• Community Health Officer (CHO) - mid-level provider
• Comprehensive Primary Health Care (CPHC)
• 12 service packages (as described in Ch6)
• Wellness activities, yoga, health promotion

Medical Officer - Job Description

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4. CHC (Community Health Centre)

Definition

Population Norm

• Plain areas: 1 CHC per 1,20,000 population (serves 4 PHCs)
• Hilly/Tribal/Difficult areas: 1 CHC per 80,000 population

Staff (IPHS norms)

Physical Infrastructure

• 30 beds (standard); 50 beds (under NHM strengthening)
• Operation Theatre (for emergency obstetric, surgical procedures)
• Labour Room with facilities for normal and assisted delivery
• NBSU (Newborn Stabilization Unit)
• Blood storage unit
• X-ray, laboratory
• Ambulance (JSY/108)

Services

• Emergency Obstetric Care (EmOC - CEmONC)
• Emergency surgical care
• Inpatient services for common illnesses
• Specialist OPD (Surgery, Medicine, O&G, Paediatrics)
• Blood transfusion (blood storage)
• Neonatal stabilization (NBSU)
• Dental services
• Physiotherapy
• Referral to District Hospital

FRU (First Referral Unit) Criteria

1. Round-the-clock Emergency Obstetric Care (EmOC) including C-section
2. Blood transfusion facility
3. Newborn care (NBSU)

Rogi Kalyan Samiti (RKS)

• Hospital management committee at CHC/DH
• Headed by District Collector/CMO
• Members: Local elected representatives, NGOs, community members, MO
• Functions: Manage user fees, maintenance, quality improvement, patient grievances

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5. ASHA (Accredited Social Health Activist)

Background

• Launched under NRHM in 2005-06
• India's largest community health worker programme
• Approximately 10.4 lakh (1.04 million) ASHAs deployed nationwide (2024)

Selection Criteria

• Female resident of the village
• Age: 25-45 years (flexible in some states)
• Married/widow/divorced
• Education: 8th class pass (minimum); preferably 10th pass
• Preference for: Married woman, resident of same village, SC/ST/OBC background
• 1 ASHA per 1000 population (1 per 2000 in some states)
• In tribal/hilly areas: 1 per 500-1000

Selection Process

• Selected by Gram Sabha (village assembly)
• Approved by Gram Panchayat
• Designated by District Health Mission/ANM

Training

• Total: 23 days initial training in 5 rounds over 12-18 months
• Training modules 1-7 (NRHM modules)
• Training by PHC MO, LHV, district trainer
• Ongoing training and capacity building

ASHA - Key Roles and Responsibilities

• Create awareness about health, nutrition, sanitation
• Mobilize community for immunization, health camps, programmes
• Accompany patients to health facility

• ANC registration and follow-up
• Escort to PMSMA (9th of month)
• Institutional delivery facilitation (JSY)
• Home visits: antenatal (3 visits), postnatal (6 HBNC visits)
• Identify high-risk pregnancies, refer promptly

• HBNC (6 visits in 42 days post-delivery)
• Newborn weighing, temperature monitoring
• Breastfeeding promotion
• Immunization mobilization and session support
• SAM identification (MUAC), referral to NRC
• Growth monitoring support

• Distribution of oral pills (Mala N), condoms (Nirodh)
• Motivate for spacing and limiting methods
• Referral for IUCD, sterilization

• DOTS supporter for TB patients
• Malaria: distribution of LLIN, fever case detection, RDT use (in some states), ACT distribution
• Leprosy: awareness, refer suspect cases
• Kala-azar: awareness, referral
• Dengue: source reduction motivation

• ASHA drug kit: ORS, Zinc, IFA, OCP, Chloroquine, paracetamol, Cotrimoxazole, Iron-folic acid, Vitamin A, condoms, Mala N
• Treatment of simple conditions using kit under protocol
• Refer complications

• ICDS linkage (AWW coordination)
• Identify SAM, MAM children
• Deworming distribution
• Vitamin A programme support

• Swachh Bharat Mission facilitation
• Open defecation free (ODF) village promotion
• WASH awareness

• Identify mental illness, refer to DMHP

• Village Health Register
• Eligible Couple Register
• HBNC visit records
• Reports to ANM/PHC

ASHA Incentives (Performance-Based)

• ASHA is not salaried but incentive-based (performance-based)
• Some states have introduced fixed monthly payments/salaries
• ASHA Sahyogini (facilitator): 1 per 10-20 ASHAs; supervisory role

ASHA Drug Kit (Module 6 Kit)

• ORS sachets
• Zinc tablets (for diarrhoea in children)
• Paracetamol tablets
• Iron and folic acid (IFA) tablets
• Vitamin A capsules
• Oral contraceptive pills (Mala N)
• Condoms (Nirodh)
• Chloroquine tablets (endemic areas)
• Emergency contraceptive pills (LNG)
• Cotrimoxazole
• Disposable delivery kit (DDK)

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6. RCH (Reproductive and Child Health Programme)

Background

• RCH Phase I: 1997-2004 (replaced CSSM - Child Survival and Safe Motherhood programme)
• RCH Phase II: 2005-2012 (aligned with NRHM)
• Now integrated into RMNCH+A under NHM (2013 onwards)

Shift from Target-Based to Need-Based Approach

• Pre-1996: Target-based family planning (each ANM/MPW had targets for sterilization, IUD, etc.)
• RCH: Target-free approach - need-based, client-centred, comprehensive
• Emphasis on quality of care, not just numbers

Components of RCH

• Family planning (all methods, voluntary choice)
• RTI/STI management (syndromic approach)
• Safe abortion services (MTP Act)
• Infertility management
• Prevention of gender-based violence

• Skilled antenatal, intrapartum, postnatal care
• Emergency obstetric care
• Prevention and management of complications
• Skilled birth attendant training

• IMNCI
• EPI/UIP - immunization
• Nutrition (Vitamin A, IFA)
• Diarrhoea management (ORT)
• ARI management

Integration with RMNCH+A

• Reproductive health + Maternal + Newborn + Child + Adolescent health
• Implemented through NHM structure
• District RCH plans, state PIPs (Programme Implementation Plans)

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SHORT NOTES

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Elements of PHC

1. Education about health problems
2. Nutritional promotion and food supply
3. Safe water and sanitation
4. MCH services + Family planning
5. Immunization
6. Control of locally endemic diseases
7. Diagnosis and treatment of common diseases and injuries
8. Essential drugs

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Principles of PHC

1. Equitable distribution - reducing urban-rural, rich-poor gap
2. Community participation - active, not passive
3. Intersectoral coordination - agriculture, education, water, housing
4. Appropriate technology - cost-effective, socially acceptable
5. Decentralization - district-level planning and management

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UHC (Universal Health Coverage)

Definition (WHO)

"Universal health coverage means that all people receive the health services they need without suffering financial hardship."

1. Who is covered: Extend to non-covered populations (population coverage)
2. What services are covered: Expand from limited to full spectrum (service coverage)
3. Cost covered: Reduce out-of-pocket payments (financial risk protection)

Key Concepts

• Not the same as free health care for all - but ensuring no one faces catastrophic expenditure
• Catastrophic health expenditure: OOP payment >10% of household income or >40% of non-food expenditure
• India's OOP expenditure: ~62% of total health expenditure (very high; target <30%)
• OOPE (Out-Of-Pocket Expenditure) drives families into poverty

India's Progress towards UHC

• Ayushman Bharat - PMJAY: Secondary and tertiary coverage (Rs. 5 lakh/family/year) for bottom 40%
• AB-HWCs (Health and Wellness Centres): Comprehensive primary health care
• State schemes: Tamil Nadu (Chief Minister's Comprehensive Health Insurance), Andhra Pradesh (AROGYASRI), Rajasthan (Chiranjeevi)
• National Health Policy 2017 target: Government health expenditure to 2.5% of GDP

SDG 3.8: Achieve UHC

• Target: Essential health services coverage index of at least 80 by 2030
• Financial risk protection: Reduce proportion with catastrophic spending

Indicators of UHC

• Service Coverage Index (SCI) - composite of 14 indicators across 4 domains
• Catastrophic health expenditure proportion
• Impoverishment due to health spending

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ASHA Responsibilities

• Community health worker - 1 per 1000 population
• Selection: 25-45 years, 8th class pass, resident woman, by Gram Sabha
• 7 key roles: Mobilize community; MCH care; Child health (HBNC); FP distribution; Disease control; Curative (drug kit); Records and reporting
• Incentive-based payment
• ASHA drug kit: ORS, zinc, paracetamol, IFA, OCP, condoms, Vitamin A, chloroquine
• ASHA = bridge between community and health system

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MO Job Description (Medical Officer at PHC)

• OPD: Diagnose and treat patients (aim 40 patients/session)
• Emergency care: 24×7 in upgraded PHCs
• Conduct normal deliveries; refer complicated cases to CHC/DH
• Minor surgical procedures (laceration, abscess)
• Supervise delivery by ANM

• Overall in-charge of PHC and all attached sub-centres (usually 6 sub-centres)
• Supervise ANM, LHV, MPW, pharmacist, lab technician
• Inspect sub-centres periodically
• Submit monthly reports to District CMO
• Maintain PHC records and registers
• Manage drug stores, indent for drugs and equipment
• Rogi Kalyan Samiti (RKS) - secretary or member

• Supervise immunization sessions
• Investigate disease outbreaks
• Disease surveillance and reporting
• Malaria, TB, leprosy programme implementation
• DOTS supervisor for TB
• Conduct health education sessions
• School health examination
• Vital statistics maintenance (births, deaths)
• Epidemic preparedness

• Implement all national health programmes (NTEP, NACP, NVBDCP, RMNCH+A)
• PMSMA: Conduct on 9th of every month
• Coordinate with ICDS, PRIs (Panchayati Raj Institutions), schools

• Prepare annual action plan for PHC area
• Prepare Village Health Plans with VHSNC support
• Prepare HMIS reports

• Coordinate with Gram Panchayat, CDPO (ICDS), school authorities
• Organize Village Health and Nutrition Days (VHND)

• Medical certification (birth, death)
• Medico-legal cases (injuries, poisoning, rape) - refer to DH/FMT
• Notifiable disease reporting
• Food adulteration surveillance
• Environmental health inspection

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Key numbers to remember: SC - 1/5000 (plain), 1/3000 (hilly); PHC - 1/30,000 (plain), 1/20,000 (hilly); CHC - 1/1,20,000 (plain), 1/80,000 (hilly); CHC = 30 beds; ASHA - 1/1000 population; 8th class pass minimum; 23 days initial training; 1.04 million ASHAs deployed. PHC has 6 inpatient beds. CHC has 5 specialists (Surgeon, Physician, O&G, Paediatrics, Anaesthesia).

Chapter 10: Nutrition

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LONG QUESTIONS

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1. PEM (Protein-Energy Malnutrition)

Definition

Classification of PEM

• Stunting (chronic malnutrition): Height for Age Z-score < -2 SD
• Wasting (acute malnutrition): Weight for Height Z-score < -2 SD

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Marasmus

• Severe restriction of both calories and protein
• Early weaning from breast milk
• Repeated infections (diarrhoea, respiratory)
• Poverty, food insecurity
• Occurs commonly in infants under 1 year

• Severe wasting - "skin and bones" appearance
• Loss of subcutaneous fat (starting from buttocks, then abdomen, then face)
• "Old man face" (premature aging - loss of buccal fat pad, Bichat's fat pad)
• Muscle wasting - visible ribs, "baggy pants" (loss of gluteal fat)
• No oedema
• Weight severely reduced (<60% expected weight for age)
• Marked irritability and hunger (vs. kwashiorkor - apathy)
• Normal hair (unlike kwashiorkor)
• Skin: dry, wrinkled; no skin lesions (unlike kwashiorkor)
• Pot belly - due to weak abdominal muscles + gas
• Alert, hungry, irritable

• Low blood glucose, low insulin
• Elevated glucagon and cortisol
• Adipose tissue mobilized (lipolysis)
• Muscle protein catabolized (gluconeogenesis)
• Metabolic adaptation to starvation

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Kwashiorkor

• Predominantly protein-deficient diet (high carbohydrate, low protein)
• Common in weaned children 1-3 years given starchy weaning foods
• Precipitated by infections (measles, diarrhoea)
• Aflatoxin exposure (controversial role)

1. Oedema (pitting) - hallmark; starts in legs, may become generalized (anasarca)
2. Growth retardation - moderate weight deficit (60-80% expected)
3. Psychomotor changes - apathy, misery, anorexia, "moon face"
4. Skin changes:
   • "Flaky paint" dermatosis / "Crazy pavement" dermatosis
   • Areas of hyperpigmentation and hypopigmentation
   • Desquamation (peeling)
   • Ulceration in severe cases
5. Hair changes:
   • Reddish/brown discoloration (flag sign - bands of normal and abnormal hair)
   • Thin, sparse, straight, silky, easily pluckable hair
   • "Flag sign" (Bandera sign) - bands of depigmented hair
6. Moon face - oedematous, rounded face
7. Fatty liver - hepatomegaly (fat accumulation due to low apolipoprotein synthesis)
8. Pot belly - hepatomegaly + weak muscles + gas
9. Anaemia - pale conjunctivae
10. Vitamin A deficiency - may coexist

• Low serum albumin (<3 g/dL; severe <2 g/dL) → oedema
• Low serum transferrin, retinol-binding protein, pre-albumin
• Low serum potassium, magnesium
• High serum ferritin (acute phase)
• Fatty liver → elevated liver enzymes

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Marasmic-Kwashiorkor

• Features of BOTH: severe wasting + oedema
• Most severe form of PEM
• Weight <60% + oedema present

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MUAC (Mid-Upper Arm Circumference) - Assessment Tool

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Global Burden

• India: ~35% of children under 5 are stunted (NFHS-5)
• ~19% are wasted; ~7.7% are severely wasted (SAM)
• ~32% are underweight
• "Double burden of malnutrition" - undernutrition + obesity coexist

Prevention of PEM

1. Promotion of breastfeeding - exclusive breastfeeding for 6 months
2. Complementary feeding from 6 months (appropriate, adequate, safe)
3. Diet diversification - balanced diet
4. ICDS programme - supplementary nutrition
5. Deworming - biannual Albendazole (reduces parasite load competing for nutrients)
6. Immunization - reduce infectious diseases
7. ORS - treat diarrhoea promptly
8. Vitamin A supplementation - reduces mortality
9. WASH - safe water, sanitation, hygiene
10. Women's education, empowerment - birth spacing, birth weight
11. Poshan Abhiyan/Mission POSHAN 2.0 - national programme

Management

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2. Balanced Diet

Definition

Nutrient Requirements (ICMR 2020 - Indian RDA)

• Adult male: 0.83 g/kg/day (sedentary ~54 g/day)
• Adult female: 0.83 g/kg/day (sedentary ~46 g/day)
• Pregnant: +23 g/day extra
• Lactating: +19 g/day extra (0-6 months)
• Children: higher per kg (1.0-1.5 g/kg/day depending on age)

Components of a Balanced Diet

Balanced Diet Plate (ICMR - "MyPlate India")

• Half plate: Vegetables + fruits
• Quarter plate: Cereals/grains
• Quarter plate: Protein (pulses + dairy/meat)
• Small portion: Fats

Nutritional Requirements - Key Points

• Energy distribution: Carbohydrates 50-60%, Fat 20-30%, Protein 10-15% of total calories
• Fats: At least 15g/day (minimum); essential fatty acids (linoleic acid, alpha-linolenic acid)
• Fibre: 25-40 g/day (dietary fibre - prevents constipation, diabetes, heart disease, colon cancer)
• Water: 2-2.5 litres/day

Cereals - Major Staple

• Provide 60-80% of calories in Indian diet
• Deficient in lysine (limiting amino acid) and tryptophan
• Rice milling removes B vitamins from outer layer → Thiamine deficiency (Beriberi)
• Wheat contains gluten (Coeliac disease in sensitive individuals)
• Millets (ragi, jowar, bajra): rich in calcium (ragi - highest), iron, fibre

Protein Quality

• Complete proteins (all essential amino acids): Animal sources - milk, egg, meat, fish
• Incomplete proteins: Plant sources - deficient in one or more essential AAs
• Complementary proteins: Combining plant proteins (cereal + pulse) improves amino acid profile (e.g., rice + dal = "protein complementation")
• NPU (Net Protein Utilization): See short notes

Special Diets

• Vegetarian diet: Adequate if includes dairy and variety of plants; may lack Vit B12, Vit D, zinc, iron, omega-3
• Vegan diet: Risk of B12, Vit D, calcium, iron, zinc, iodine deficiency
• Ketogenic diet: High fat, very low carbohydrate; used in epilepsy, obesity (medical supervision)

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3. IDD (Iodine Deficiency Disorders)

Iodine in Nutrition

• RDA: 150 mcg/day (adults); 250 mcg/day (pregnancy and lactation)
• Sources: Seafood (best), iodized salt, seaweed, dairy
• Deficiency: Iodine-deficient areas - Himalayan foothills, Gangetic plain, inland areas
• Assessment: Urinary iodine excretion (UIE); median >100 mcg/L = adequate

Spectrum of IDD (across life cycle)

Types of Goitre

• Grade 0: No goitre
• Grade 1: Palpable (not visible even with neck extended)
• Grade 2: Visible with neck in normal position

Cretinism

• Neurological cretinism (more common in India): Intellectual disability, deaf-mutism, spastic diplegia; due to maternal iodine deficiency (critical period: 8-12 weeks gestation)
• Myxoedematous cretinism: Hypothyroid features predominate; dwarfism, dry skin, myxoedema; less common in India

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4. Iron Deficiency Anaemia

Definition

Prevalence in India (NFHS-5)

• Children 6-59 months: 67.1% anaemic
• Women 15-49 years: 57% anaemic
• Pregnant women: 52.2% anaemic
• Men 15-49 years: 25% anaemic

Iron Metabolism

• Total body iron: 3-4 g (male), 2.5 g (female)
• Functional iron: Haemoglobin (~65%), myoglobin (~10%), tissue enzymes
• Storage iron: Ferritin, haemosiderin (in liver, spleen, bone marrow)
• Transport iron: Transferrin (bound to transferrin - normally 30% saturated)
• Recommended Daily Allowance (ICMR 2020): Male: 17 mg/day; Female: 21 mg/day (premenopausal); Pregnancy: 35 mg/day

Dietary Iron

• Haem iron (from animal sources - meat, fish, poultry): 15-35% bioavailability
• Non-haem iron (from plant sources - cereals, pulses, green vegetables): 1-10% bioavailability
• Enhancers of iron absorption: Vitamin C (most important), meat factor, acidic pH, ferrous > ferric
• Inhibitors of iron absorption: Phytates (cereals), oxalates (spinach), tannins (tea, coffee), calcium, antacids, polyphenols

Stages of Iron Deficiency

1. Pre-latent (Storage depletion): Serum ferritin ↓; Hb normal; Transferrin saturation normal
2. Latent (Transport depletion): Serum ferritin ↓↓; Serum iron ↓; TIBC ↑; Transferrin saturation ↓; Hb still normal
3. Overt Iron Deficiency Anaemia: All above + Hb ↓; microcytic hypochromic RBCs; clinical symptoms

Clinical Features

• General: Pallor (conjunctiva, nail beds, palmar creases, tongue), fatigue, weakness, exertional dyspnoea
• Specific to iron deficiency:
  • Koilonychia (spoon-shaped nails)
  • Angular stomatitis, glossitis
  • Dysphagia (Plummer-Vinson/Paterson-Brown-Kelly syndrome) - with oesophageal web
  • PICA (pagophagia = ice eating; geophagia = dirt eating)
  • Irritability, poor concentration, impaired cognitive function (in children)
  • Restless leg syndrome

Diagnosis

• CBC: Low Hb, low MCV (<80 fL), low MCH (<27 pg), low MCHC (<32%)
• Peripheral smear: Microcytic hypochromic RBCs, anisocytosis, poikilocytosis, pencil cells, target cells
• Serum ferritin: Best single test to assess iron stores (low in IDA: <12-15 mcg/L); elevated in infection (acute phase reactant)
• Serum iron: Low (<60 mcg/dL)
• TIBC: High (>400 mcg/dL)
• Transferrin saturation: Low (<15%)

Treatment

• Therapeutic dose: Elemental iron 3-6 mg/kg/day in 2-3 divided doses (children); 100-200 mg/day (adults)
• Duration: Continue 3 months after Hb normalizes to replenish stores
• Form: Ferrous sulphate (cheapest, most common), ferrous gluconate, ferrous fumarate
• Parenteral iron (IV/IM): For malabsorption, intolerance, compliance issues, severe anaemia near surgery
  • Iron sucrose (safest IV), Ferric carboxymaltose (FCM - single large dose)
• Blood transfusion: Hb <7 g/dL with symptoms; or emergency (Hb <6 in pregnancy)
• Treat underlying cause: Deworming (hookworm), treat bleeding disorders

Prevention (Programmes)

• WIFS: Weekly IFA for adolescents
• IFA in pregnancy: 100 mg iron + 500 mcg folic acid daily for 180 days
• IFA for children 6-59 months: 1 mg/kg/day liquid IFA daily
• ANAEMIA MUKT BHARAT (AMB): 6×6×6 strategy (see Chapter 6)
• Fortification: Iron-fortified salt, wheat flour, rice fortification (under FSSAI)
• Dietary diversification: Green leafy vegetables, Vitamin C-rich foods
• Deworming: Biannual Albendazole (reduces hookworm load)

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5. Nutritional Assessment

Definition

Methods - "ABCD" of Nutritional Assessment

• Weight: Most commonly used; weighed on calibrated scale, light clothing, no shoes
• Height/Length: Recumbent length (<2 years), standing height (>2 years)
• BMI (Body Mass Index): Weight (kg) / Height² (m²)
  • WHO cut-offs: <18.5 = underweight; 18.5-24.9 = normal; 25-29.9 = overweight; ≥30 = obese
  • Asian cut-offs (India/WHO Asia-Pacific): Overweight ≥23 kg/m²; Obese ≥27.5 kg/m²
• MUAC (Mid-Upper Arm Circumference): 6-59 months children, pregnant women
• Head circumference: Reflects brain growth; normal at birth ~34 cm; 1 year ~47 cm
• Chest circumference: Head > Chest at birth; Head = Chest at 1 year; Head < Chest after 1 year
• Skin fold thickness: Triceps, subscapular (reflects body fat); measured with Harpenden caliper
• Growth charts: Z-scores (WAZ, HAZ, WHZ) - plotted on WHO growth standards

• Serum proteins: Albumin (half-life 20 days - chronic status), Pre-albumin/Transthyretin (2 days - recent acute changes), Transferrin (8 days), Retinol-binding protein (12 hours)
• Haemoglobin: Anaemia assessment
• Serum iron, ferritin, TIBC: Iron status
• Serum vitamins: Retinol (Vit A), 25-OH Vitamin D, Vitamin C, B12, folate
• Urinary nitrogen: Nitrogen balance (positive = anabolism; negative = catabolism)
• Urinary creatinine-height index: Estimates muscle mass
• Urinary iodine excretion: Iodine status

• Head-to-toe examination for signs of nutritional deficiencies:
  • Hair: Flag sign (protein deficiency), alopecia (zinc, biotin)
  • Eyes: Xerophthalmia (Vit A), Bitot's spots, angular palpebritis (riboflavin)
  • Face: Moon face (kwashiorkor), pallor (anaemia)
  • Mouth: Angular stomatitis (riboflavin, niacin, iron), cheilosis, glossitis, bleeding gums (Vit C - scurvy)
  • Skin: Flaky paint dermatosis (kwashiorkor), pellagrous dermatitis (niacin), follicular hyperkeratosis (Vit A)
  • Nails: Koilonychia (iron deficiency)
  • Legs: Pitting oedema (kwashiorkor, Vit B1), Bitot's spots (Vit A), night blindness

• 24-hour dietary recall: Most commonly used; person recalls all food/drink consumed in past 24 hours; single recall underestimates usual intake; 3-day recall more accurate
• Food frequency questionnaire (FFQ): Lists food items, frequency of consumption (daily/weekly/monthly); good for usual intake
• Diet history: Detailed interview about usual dietary patterns, food habits
• Food diary/record: Prospective recording for 3-7 days; most accurate but requires cooperation
• Household food balance sheet: Food available to household (production + purchase - wastage/storage)
• Duplicate food collection: Weighed analysis of duplicate portion; gold standard but impractical

PEM Grades - CIAF (Composite Index of Anthropometric Failure)

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6. Nutrition Programmes

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SHORT NOTES

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Glycaemic Index (GI)

• Measures how quickly a carbohydrate-containing food raises blood glucose relative to a reference food (glucose or white bread)
• Formula: GI = (Area under blood glucose curve for test food / Area under blood glucose curve for reference) × 100
• Reference: Glucose = 100; White bread = 100

• Diabetics and insulin-resistant individuals benefit from low-GI diet
• Low GI → slower glucose absorption → less insulin spike → better glycaemic control
• Glycaemic Load (GL): GI × Carbohydrate content of serving / 100; better clinical predictor than GI alone
• Limitation: GI tested in isolated food; mixed meals change GI considerably

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NPU (Net Protein Utilization)

• Measure of protein quality that accounts for both digestibility and biological value
• Formula: NPU = (Nitrogen retained / Nitrogen ingested) × 100
• Combines: Digestibility + Biological Value (BV)
• NPU = Digestibility × Biological Value (BV)

• Egg (whole): NPU ~94% (reference/near perfect protein)
• Milk: NPU ~82%
• Meat/fish: NPU ~75-80%
• Soyabean: NPU ~61%
• Wheat: NPU ~40-60%
• Maize: NPU ~36%
• Rice: NPU ~57%

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Xerophthalmia (Vitamin A Deficiency)

• Fat-soluble vitamin (stored in liver)
• Sources: Liver, egg yolk, dairy, orange/yellow vegetables (beta-carotene - provitamin A)
• RDA: 600 mcg retinol equivalents (RE)/day for adult; 800 mcg/day pregnancy; 950 mcg/day lactation
• 1 mcg retinol = 6 mcg beta-carotene
• Deficiency effects: Night blindness, xerophthalmia, increased susceptibility to infections, impaired growth, anaemia
• Toxicity (hypervitaminosis A): Teratogenic (excess in pregnancy); raised ICP (pseudotumor cerebri); hepatotoxicity; hair loss, dry skin

• 9 months: 1 lakh IU with measles vaccine
• 18 months - 5 years: 2 lakh IU every 6 months

• Day 1: Vit A 200,000 IU orally
• Day 2: Vit A 200,000 IU orally
• After 1-4 weeks: Vit A 200,000 IU orally
• Children <1 year or <8 kg: Half dose (100,000 IU each)

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Food Pyramid

• Visual guide to recommended proportions of different food groups in daily diet
• Originally developed by USDA (USA) in 1992
• India: ICMR/NIN recommended food pyramid

• Base (eat most): Grains/cereals
• Next level: Vegetables | Fruits
• Above: Dairy | Protein (meat/beans)
• Apex (eat least): Fats, oils, sweets

• Plate divided into 4 sections: Fruits, Vegetables, Grains, Protein
• Small circle (dairy) beside plate
• Half the plate = fruits and vegetables

• Base: Cereals, millets, pulses (eat most)
• 2nd level: Vegetables + Fruits
• 3rd level: Milk + Animal products
• Apex: Fats + Sugar (eat least)

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My Plate

• Make half your plate fruits and vegetables
• Make at least half your grains whole grains
• Switch to fat-free or low-fat dairy
• Vary your protein routine
• Reduce sodium, saturated fat, added sugars

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Dietary Fibre

1. Soluble fibre (fermentable): Pectin (fruits), guar gum, oat beta-glucan, psyllium; dissolves in water → gel; fermented by gut bacteria → SCFA
2. Insoluble fibre (non-fermentable): Cellulose, hemicellulose, lignin (vegetables, whole grains, wheat bran); does not dissolve; adds bulk to stool

• Prevents constipation (increases stool bulk)
• Reduces serum cholesterol (soluble fibre - binds bile acids)
• Improves glycaemic control (slows glucose absorption - low GI)
• Reduces risk of colorectal cancer
• Promotes satiety, aids weight management
• Feeds gut microbiome (prebiotic effect)

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Food Fortification

1. Mandatory fortification: Government mandated; e.g., iodized salt (mandatory in India)
2. Voluntary/commercial fortification: By food industry; e.g., fortified cereals, energy drinks
3. Market-driven fortification
4. Targeted/complementary food fortification: For specific high-risk groups

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Food Adulteration

• Prevention of Food Adulteration (PFA) Act, 1954 - repealed and replaced
• Food Safety and Standards Act (FSSA), 2006 - current; FSSAI (Food Safety and Standards Authority of India)
• FSSAI: Regulatory body for food safety standards in India

• Metanil yellow (coal tar dye): Carcinogenic
• Sudan red: Carcinogenic
• Lead chromate: Lead poisoning
• Argemone seeds: Epidemic dropsy
• Kesari dal: Lathyrism

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Lathyrism

• Endemic in MP, Bihar, UP, Orissa (Indian states where khesari dal grown)
• Occurs in famines when Lathyrus consumed as staple
• Affects young males predominantly (protective effect of estrogens?)

• Irreversible spastic paraparesis (lower limb spasticity and weakness)
• Upper motor neuron signs: spasticity, hyperreflexia, extensor plantar
• "Scissors gait" due to spastic diplegia
• Sensory system preserved
• Bowel and bladder usually unaffected
• Once established, irreversible (no treatment)

• Avoid exclusive/excessive consumption of Lathyrus sativus
• Soak and boil discarding water (leaches BOAA)
• Blending with other grains (dilution)
• Ban on sale (under PFA Act) - but often ignored in famines

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Epidemic Dropsy

• Outbreaks in India (most famously 1998 Delhi epidemic)
• Argemone seeds mixed with mustard seeds, pressed together for oil
• "Pungency test": Argemone oil is pungent (same as mustard), making adulteration difficult to detect by consumers

1. Oedema - bilateral pitting oedema of legs, ascites (most prominent feature)
2. Diarrhoea, abdominal pain, nausea
3. Erythema of skin (brick-red discoloration)
4. Glaucoma (raised intraocular pressure)
5. Cardiovascular: tachycardia, CHF (cardiac failure)
6. Anaemia
7. Liver enlargement (hepatomegaly)
8. Severe cases: death from cardiac failure

• Nitric acid test: A few drops nitric acid + oil → yellow color = argemone present (Burchfield's test)

• Stop adulterated oil
• Symptomatic: Diuretics for oedema, cardiac support
• No specific antidote

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Endemic Ascites (Veno-occlusive Disease / Budd-Chiari)

• Heliotropium (common in India - contaminating wheat and millet)
• Crotalaria
• Also: Senecio genus

• Rural areas; crops contaminated with PA-containing weeds
• India: Rajasthan, Gujarat, Maharashtra
• Also called "Bread poisoning" when cereal flour contaminated

• Hepatomegaly, tender
• Ascites (main feature - "endemic ascites")
• Jaundice
• Portal hypertension → variceal bleeding
• Liver failure in chronic cases

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Aflatoxicosis

• High-dose exposure
• Vomiting, abdominal pain, pulmonary oedema, cerebral oedema
• Acute liver failure (haemorrhagic necrosis)
• High mortality
• Example: India outbreak (Gujarat 1974 - 106 deaths from contaminated maize)

• Low-level prolonged exposure
• Hepatocellular carcinoma (HCC) - major consequence (aflatoxin B1 is Group 1A carcinogen - IARC)
• Synergistic with Hepatitis B → very high HCC risk
• Immunosuppression
• Growth retardation in children

• Proper storage (cool, dry, <13% moisture)
• Aflatoxin testing (TLC, ELISA, HPLC) in food
• FSSAI standards: Aflatoxin <15 ppb total (30 ppb B1) in food; <10 ppb in infant food
• Reject visually mouldy/damaged grains

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Vitamin A Prophylaxis

• Total: 9 doses from 9 months to 5 years
• Delivered as biannual rounds (every 6 months) at AWC, immunization sessions
• Vitamin A given orally as oily solution (dark amber bottle)

• Reduces all-cause child mortality by 24%
• Reduces diarrhoea mortality by 33%
• Reduces measles severity
• Reduces anaemia

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ICDS (Integrated Child Development Services)

• World's largest nutrition programme (launched 1975)
• Anganwadi Centre: serves 400-800 children, 150-200 pregnant/lactating women per AWC
• Supplementary Nutrition: Provided to children 6 months-6 years and pregnant/lactating women for 300 days/year (25 days/month)
  • Children 6-72 months: 500 kcal + 12-15g protein
  • Severely malnourished children: 800 kcal + 20-25g protein
  • Pregnant and lactating women: 600 kcal + 18-20g protein
  • Adolescent girls (in some states): 500 kcal + 25g protein

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Poshan Abhiyan (Mission POSHAN 2.0)

• Launched March 8, 2018 (International Women's Day)
• Prime Minister's Overarching Scheme for Holistic Nutrition
• Target: Reduce stunting, underweight, low birth weight, anaemia (by 2%, 2%, 2%, 3% annually respectively)

• Merged ICDS + PMMVY + National Crèche Scheme + several nutrition schemes
• Target beneficiaries: Children 0-6 years, Pregnant and Lactating women, Adolescent Girls
• Key features:
  • POSHAN Tracker app (real-time monitoring of AWC services, beneficiary data)
  • Convergence of ICDS, NHM, SBCC (Social and Behaviour Change Communication)
  • Community-based nutrition management
  • Poshan Maah: September = Nutrition Month (month-long activities)
  • Poshan Pakhwada: Fortnight of nutrition activities (March)
  • Focus on first 1000 days (conception to 2 years) as critical window

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Mid-Day Meal (PM POSHAN)

• Renamed PM POSHAN (Pradhan Mantri Poshan Shakti Nirman) in 2021
• Classes 1-8; government schools; free cooked meal
• Nutritional norms: Primary 450 kcal/12g protein; Upper Primary 700 kcal/20g protein
• Benefits: Reduces hunger, improves attendance, reduces dropout, reduces malnutrition

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Anaemia in Pregnancy

• Iron deficiency (most common - >70%)
• Folate deficiency
• Vitamin B12 deficiency
• Hookworm infestation
• Malaria (endemic areas)
• Haemoglobinopathies (sickle cell, thalassemia)

• Increased maternal mortality (indirect cause of 20% maternal deaths in India)
• Heart failure (severe anaemia)
• Increased infection susceptibility
• PPH risk increased
• Poor wound healing

• LBW, prematurity
• Perinatal mortality increased
• Fetal iron deficiency → poor neurodevelopment

• IFA supplementation: 100 mg elemental iron + 500 mcg folic acid daily for 180 days
• Treatment dose for moderate anaemia: 200 mg elemental iron/day
• IV iron (FCM - Ferric Carboxymaltose): For severe anaemia/non-responders
• Blood transfusion: Hb <7 with symptoms; Hb <6 anytime; any Hb <8 near term
• Treat underlying cause (deworming, malaria treatment)

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Micronutrients

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Marasmus and Kwashiorkor

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Iodized Salt

• Universal Salt Iodization (USI): all edible salt
• Added as Potassium Iodate (KIO₃) - more stable than potassium iodide
• 30 ppm at production; 15 ppm at consumer level
• Storage: Cool, dry, dark (iodine volatilizes with heat, light, moisture)
• Use iodized salt AFTER cooking (heat reduces iodine content)
• Double Fortified Salt (DFS) = Iodine + Iron = addresses both IDD and IDA simultaneously
• Spot test kit: Starch-iodide test paper (turns blue with iodine)

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Milk-Borne Diseases

• Pasteurization (most effective and widely used):
  • HTST (High Temperature Short Time): 72°C for 15 seconds
  • LTLT (Low Temperature Long Time): 63°C for 30 minutes
  • UHT (Ultra High Temperature): 135°C for 2 seconds
• Proper milking hygiene
• Cold chain maintenance
• Milk quality testing: MBR (Methylene Blue Reduction) test

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Key numbers to remember: Marasmus = <60% weight, no oedema; Kwashiorkor = 60-80% weight + oedema; MUAC <11.5 cm = SAM; Anaemia in pregnancy = Hb <11 g/dL; IDA treatment = 100-200 mg elemental iron/day; Vitamin A at 9 months = 1 lakh IU; 18 months to 5 years = 2 lakh IU every 6 months (9 total doses); Egg NPU ~94% (near perfect protein); Aflatoxin B1 = most potent natural carcinogen; Lathyrism = Lathyrus sativus → BOAA → spastic paraparesis; Epidemic Dropsy = Argemone oil → Sanguinarine → oedema.